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A   TREATISE   ON  THE  DISEASES   OF   THE 
NERVOUS    SYSTEM. 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseondiseas02ross 


A    TREATISE 


THE    DISEASES 


NERVOUS    SYSTEM. 


JAMES     ROSS,     M.D. 

MEMBER   OP   THE   EOTAL    COLLEGE   OF   PHYSICIANS,    LONDON  ; 

ASSISTANT    PHYSICIAN    TO     THK     MANCHHSTEB    KOYAL    INFIKMART  ; 

CONSULTING  PHYSICIAN    TO   THE    MANCHESTER 

SOUTHERN    HOSPITAL. 


ILLUSTRATED     WITH   LITHOGRAPHS,    PIIOTOGHAPHS,    AND 
TWO  HUNDRED    AND    EIGHTY   WOODCUTS. 


Volume   II. 


NEW  YORK : 

WILLIAM    WOOD    &    COMPANY^ 

1882. 


IZ2Z 
V.  2— 


CO 


o 

3S 


CONTENTS    OF    VOLUME    II. 


BOOK   II. 

SPECIAL  PATHOLOGY  OF  THE  NERVOUS  SYSTEM  (Continued). 

Part  III. 

DISEASES    OF    THE    SPINAL    COED    AND    MEDULLA 
OBLONGATA. 

PAGE. 

Chapter    I.  Anatomical  and  Physiological  Introduction    ...        3 

Chapter  II.  Morbid  Anatomy  and  Classification  of  the 
Diseases  of  the  Spinal  Cord  and  Medulla 
Oblongata. 

(i.)  Morbid  Anatomy      84 

(ii.)  Classification       100 

Chapter  III.  System  Diseases  of  the  Spinal  Cord  and 
Medulla  Oblongata. 

(i.)  Poliomyelopathies. 

1.  Poliomyelitis  Anterior  Acuta  ...         ...  105 

2.  Poliomyelitis  Anterior  Chronica  ...  136 

3.  Progressive  Muscular  Atrophy  ...         ...  145 

4.  Primary  Labio-glosso-Laryngeal  Paralysis  173 

5.  Pseudo- Hypertrophic  Paralysis  ...  185 

Chapter  IV.   System    Diseases    of    the    Spinal    Coed    and 
Medulla  Oblongata  {continued). 
(ll.)  Leucomyelopathies. 

1.  Progressive  Locomotor  Ataxy  ...         ...     211 

2.  Sclerosis  of  the  Columns  of  GoU  ...  249 

3.  Sclerosis  of  the  Direct  Cerebellar  Tracts    ...     250 

4.  Lateral  Sclerosis 251 


VI  TABLE   OF   CONTENTS. 

PAGE. 

Chapter  V.  Mixed  Diseases  of  the  Spinal  Cord  and 
Medulla  OsLONaATA. 

(i.)  Paralysis  Ascendens  Acuta  264 

(n.)  Acute  Diffused  Myelitis  272 

(in.)  Chronic  Diffused  Myelitis 292 

(iv.)  Myelomalacia      ... 308 

Chapter  VI.  Vascular    Diseases    of    the   Spinal   Cord   and 
Medulla  Oblongata. 
(i.)  AnBsmia,  Thrombosis,  and  Embolism  of  the  Spinal  Cord 
and  Medulla  Oblongata. 

1.  A nsemia  of  the  Spinal  Cord  ...         ...         ...     310 

2.  Anaemia  of  the  Medulla  Oblongata — Throm- 

bosis and  Embohsm — Necrotic  Softening.    313 

(ii.)  Hypereemia  and  Haemorrhage  of  the  Spinal  Cord  and 
Medulla  Oblongata. 

1.  Hyperaemia  of  the  Spinal  Cord  and  its  Mem- 

branes ...         ...         ...         ...         ...     317 

2.  Haemorrhage    into    the    substance    of    the 

Spinal  Cord 321 

3.  Hyperaemia  and  Haemorrhage  of  the  Medulla 

Oblongata 327 

Chapter  VII.  Functional  and  Secondary  Diseases  of  the 
Spinal  Cord  and  Medulla  Oblongata. 

(i.)  Spinal  Irritation       332 

(il)  Neurasthenia  Spinalis  ...         ...         ...         ...         ...  335 

(ill.)  Keflex  and  Secondary  Paraplegia 339 

(iv.)  Saltatory  Spasm  ...         341 

(v.)  Tonic  Spasms  in  Muscles  capsible  of  Voluntary  Movement  342 

(vi.)  Intermittent  Spinal  Paralysis        ...         ...         ...         ...  343 

(vil)  Toxic  Spinal  Paralysis 344 

(viii.)  Hysterical  Paraplegia         ...         ...         344 

Chapter  VIII.  Traumatic  Diseases,  Tumours,  and  Abnor- 
malities OP  the  Spinal  Cord  and  Medulla 
Oblongata. 

(i.)  Wounds  of  the  Spinal  Cord  and  Medulla  Oblongata      . . .  346 
(ii.)  Slow   Compression   of    the    Spinal   Cord   and    Medulla 

Oblongata  ...         ...         ...         351 

(in.)  Hemiplegia  et  Hemiparaplegia  Spinalis         361 

(iv.)  Concussion  of  the  Spinal  Cord      ...         ...         368 

(v.)  Tumours  of  the  Spinal  Cord  and  Medulla  Oblongata  372 


TABLE   OF   CONTENTS.  Vll 

PAGE. 

Chapter  IX.  Diseases  of  the  Membranes  op  the  Spinal  Cord 
AND  Medulla  Oblongata. 
(i.)  Vascular  Diseases  of  the  Membranes. 

1.  Hypersemia  of  the  Spinal  Membranes         ...     381 

2.  Meningeal  Apoplexy  (Hsematorrhachis)...  381 
(ii.)  Pachymeningitis  Spinalis. 

1.  Pachymeningitis  Spinalis  Externa   ...         ...     384 

2.  Pachymeningitis   Spinalis   Interna    (Hyper- 

trophica  et  Hsemorrhagica)  386 

(ill.)  Leptomeningitis  Spinalis. 

1.  Leptomeningitis  Spinalis  Acuta 391 

2.  Leptomeningitis  SpinaUs  Chronica  ...         ...     396 

(iv.)  Tumours  of  the  Spinal  Membrane      ...  400 

(v.)  Deformities  of  the  Spinal  Membranes      404 

Part  IV. 

DISEASES  OF  THE  ENCEPHALON. 

Chapter    I.    Anatomical  and  Physiological  Introduction   . . .    409 

Chapter  II.  Morbid  Anatomy  and  Classification  of  the 
Diseases  of  the  Encephalon. 

(l)  Morbid  Anatomy  of  the  Encephalon 501 

(ii.)  Classification  of  the  Diseases  of  the  Encephalon 508 

Chapter  III.  General  Consideration  of  Focal  Diseases, 
According  to  the  Nature  of  the  Lesion. 

1.  Occlusion  of  the  Intracranial  Vessels 511 

{a)  Occlusion  of  the  Cerebral  Arteries 511 

(6)  Thrombosis  of  the  Cerebral  Sinuses      ...  518 

(c)   Occlusion  of  the  Cerebral  Capillaries  ...     523 

Chapter  IV.  General  Consideration  op  Focal  Diseases, 
According  to  the  Nature  of  the  Lesion  (con- 
tinued). 

2.  Intracranial  Hsemorrhage         ....         ....         ...         ...  525 

(a)  Cerebral  Haemorrhage  ...         ...         ...     525 

(6)   Meningeal  Haemorrhage 543 

Chapter  V.  General  Consideration  of  Focal  Diseases, 
According  to  the  Nature  op  the  Lesion  (con- 
tinued). 

3.  Intracranial  Tumours  547 


vm  TABLE   OF   CONTENTS. 

PAGE. 

Chapter  VI.  Special  Consideration  of  Focal  Diseases, 
According  to  the  Localisation  of  the  Lesion. 

1.  Affections  of  the  Peduncular  Fibres  and  Internal  Capsule. 

a.  Affections  of  the  Pyramidal  Tract. 

(i.)  Hemiplegia 568 

(ii.)  Hemispasm       569 

b.  Affections  of  the  Sensory  Peduncular  Tract. 

Hemiansesthesia  ...         ...         ...  582 

Chapter  VII.  Special  Consideration  of  Focal  Diseases, 
According  to  the  Localisation  of  the  Lesion 
(continued). 

2.  Cortical  Lesions. 

a.  Lesions  in  the  Area  of  the  Middle  Cerebral 

Artery, 
(i.)  Monospasms  and  Unilateral   Convul- 
sions  ...         ...         ...         ...         ...     594 

(ii.)  Cortical  Paralyses  and  Monoplegise  ...     599 
(iii.)  Affections    of    Speech    from    Cortical 

Disease  ...     612 

b.  Lesions  in  the  Area  of  the  Posterior  Cere- 

bral Artery        633 

c.  Lesions  in  the  Area  of  the  Anterior  Cere- 

bral Artery        ...         ...         ...         ...     640 

Chapter  VIII.  Special  Consideration  of  Focal  Diseases, 
According  to  the  Localisation  op  the  Lesion 
(continued). 

3.  Lesions  of  the  Basal  Ganglia,  External  Capsule,   and 

Claustrum. 

(a)  Lesions  of  the  Lenticular  Nucleus  ...         ...  643 

(6)  Lesions  of  the  Caudate  Nucleus            ...  645 

(c)  Lesions  of  the  Optic  Thalamus        ...         ...  649 

(d)  Lesions  of  the  Corpora  Quadrigemina  . . .  649 

(e)  Lesions   of    the    Claustrum    and    External 

Capsule 650 

(/)  Lesions  of  the  Base  of  the  Skull. 

(i.)  Lesions  of  the  Anterior  Fossse  of  the 

Skull       651 

(ii.)  Lesions  of  the  Middle  Fossae  of  the 

Skull       651 

(iii.)  Haemorrhage   into  the    Lateral  Ven- 
tricles     ...         ...         ...         ...         ...     655 

(iv.)  Tumours  in  the  neighbourhood  of  the 

Pituitary  Body 655 


TABLE   OF   CONTENTS.  IX 

PAGE. 

Chapter  IX.  Special  Consideration  of  Focal  Diseases, 
According  to  the  Localisation  of  the  Lesion 
{contimied). 

4.  Lesions  localised  in  the  Structures  situated  below  the 
Tentorium. 

a.  Lesions  in  the  Pons  and  Pedmicles  of  the 

Cerebrum  ...         661 

h.  Lesions  in  the  Peduncles  of  the  Cerebellum     670 
c.  Lesions  in  the  Cerebellum ...     671 


Chapter     X.    Diffused  Diseases  op  the  Encephalon. 
(i.)  Anaemia  and  Hypersemia  of  the  Brain. 

(i.)  Anaemia  of  the  Brain  ...         •■•     685 

(ii.)  Hypersemia  of  the  Brain  ...         ...         •••  693 


Chapter  XL    Diffused    Diseases    op    the    Encephalon    {con- 
tinued). 

(ii.)  Atrophy  and  Hypertrophy  of  the  Brain. 

(i.)  Atrophy  of  the  Brain  ...         703 

(ii.)  Hypertrophy  of  the  Brain         706 


Chapter  XII.   Diffused   Diseases   of   the  Encephalon    {con- 
tinued). 

(ill.)  Shock  and  Concussion. 

(i.)  Shock 710 

(ii.)  Concussion  ...         ...         ...         ...         ...  716 


Chapter  XIII.  Diffused   Diseases   of  the  Encephalon  {con- 
tinued). 

(iv.)  Encephalitis. 

1.  Diffused  or  General  Encephalitis      724 

2.  Partial  or  Local  Encephahtis       724 

a.  Acute  Encephalitis  complicating  affections 

of  the  Bones  of  the  Skull       727 

b.  Acute  Pyaemic  Encephalitis       728 

c.  Encephahtis  around  pre-existing  Lesions  in 

the  Brain  728 

d.  Chronic  Abscess  of  the  Brain 731 


X  TABLE   OF   CONTENTS. 

PAGE. 

Chapter  XIV.  Diseases  of  the  Membranes  of  the  Brain. 
(i.)  Diseases  of  the  Dura  Mater. 

(i.)  External  Pachymeningitis        ...         ...         ...  743 

(ii.)  Internal  Hsemorrhagic  Pachymeningitis 745 

Chapter  XV.  Diseases  of  the  Membranes  of  the  Brain  {con- 
tinued). 
(ii.)  Diseases  of  the  Pia  Mater. 

1.  Leptomeningitis  Infantium    ...         ...         ...         ...     751 

2.  Tubercular  Meningitis      ...         754 

Chronic  Hydrocephalus   ...         ...         ...         ...  770 

3.  Basilar  Meningitis  ...         ...         ...         ...  774 

4.  Meningitis  of  the  Convexity  of  the  Brain  ...         ...  778 

5.  Metastatic  Meningitis       784 

6.  Traumatic  Meninfflitis  ...         786 


Part  V. 
DISEASES  OF  THE  ENCEPHALO-SPINAL  SYSTEM. 

Chapter  I.  Paralysis  Agitans,  and  Multiple  Sclerosis. 

(i.)  Paralysis  Agitans 791 

(ii.)  Multiple  Sclerosis  ...  801 

Chapter  II.  Chorea,  and  Meniere's  Disease. 

(l.)  Chorea  814 

(ii.)  M6nidre's  Disease  830 

Chapter  III.    Epidemic  Cerebro-spinal  Meningitis,  Tetanus, 
and  Hydrophobia. 
(r.)  Epidemic  Cerebro-spinal  Meningitis         ...         ...         ...     834 

(ii.)  Tetanus 842 

(ill.)  Hydrophobia  855 

Chapter  IV.  Hysteria       865 

Chapter  V.    Catalepsy,  Trance,  Ecstasy,  and  other  Allied 
Conditions. 

(i.)  Catalepsy       904 

(II.)  Trance     907 

(ill.)  Ecstasy  907 

(iv.)  Somnambulism  and  Hypnotism  908 


TABLE   OF   CONTENTS.  XI 

PAGE. 

Chapter  VI.  Epilepsy  and  Eclampsia. 

(l)  Epilepsy         913 

(n.)  Eclampsia  945 


Chapter  VII.  Toxic,  and  Febrile  and  Post-febrile  Nervous 
Disorders. 

(i.)  Alcoholic  Nervous  Diseases  ...         ...  953 

(ll.)  Saturnine  Nervous  Diseases     ...         ...         ...         ...  955 

(ill.)  Mercurial  Nervous  Diseases  961 

(iv.)  Syphilitic  Nervous  Diseases 962 

(v.)  Febrile  and  Post-Febrile  Nervous  Diseases        975 


BOOK    II. 


SPECIAL  PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 


SPECIAL  PATHOLOGY  OF  THE  NERVOUS 

SYSTEM. 


Part  HI— DISEASES  OF  THE    SPINAL    CORD   AND 
MEDULLA  OBLONGATA. 


CHAPTER   I. 

ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

(I.) -STRUCTURE  OF  THE  SPINAL  MEMBRANES. 

The  spinal  cord  is  surrounded  by  a  compound  connective-tissue 
sheath,  consisting  of  (1)  the  dura  niater,  (2)  the  arachnoid, 
and  (3)  the  pia  mater. 

§  349.  (1)  The  dura  mater  is  composed  of  lamellae,  each  of 
which  consists  of  a  layer  of  parallel  bundles  of  fine  connective- 
tissue  fibres.  Flattened,  more  or  less  branched  connective-tissue 
cells  lie  between  the  lamellae ;  they  lie  in  spaces  which  com- 
municate with  one  another,  the  latter  constituting  the  lymph- 
canalicular  system.  The  inner  surface  of  the  dura  mater  is 
lined  by  a  thin  hyaline  elastic  membrane,  which  is  covered  by 
a  continuous  layer  of  nucleated  endothelial  plates.  The  outer 
surface  is  also  covered  with  a  continuous  layer  of  endothelium. 
The  dura  mater  is  richly  supplied  with  blood-vessels  and  nerves. 

(2)  The  arachnoid  sheath  is  a  delicate  membrane,  composed 
of  parallel  bundles  of  connective-tissue  fibres,  longitudinally 
disposed,  with  connective-tissue  corpuscles  lying  between  them. 
The  outer  surface  is  covered  by  one  or  two  layers  of  endothelial 
plates,  constituting  an  endothelial  membrane.  On  the  inner 
surface  is  a  fenestrated  membrane,  composed  of  anastomosing, 
transversely  disposed  trabeculse  of  connective-tissue  fibres,  the 


4  ANATOMICAL  AND  PHYSIOLOGICAL   INTEODUCTION, 

inner  surface  of  which  is  covered  by  a  single  layer  of  endo- 
thelial plates. 

(3)  The  pia  mater  consists  of  an  external  and  internal 
portion.  The  former  is  composed  of  longitudinal  bundles  of 
connective-tissue  fibres,  and  its  external  surface  is  covered  by 
an  endothelial  layer  (Klein).    The  internal  portion,  or  intima  pise, 

Fig.  100. 


Fig.  100  (After  Key  and  Retzius).  Transverse  Section  of  the  Spinal  Cord  in  the 
ujiper  dorsal  region,  ivith  its  membranes. — Close  on  the  inner  surface  of  the  dura 
(A)  lies  the  arachnoid  (B),  which  is  thrown  into  longitudinal  folds  at  intervals. 
In  the  posterior  subarachnoidal  space  (the  part  behind  the  ligamenta  denticu- 
lata,  G),  the  septum  posticum  (G)  may  be  observed  in  the  middle,  with  its 
numerous  partitions,  along  with  the  subarachnoidal  spaces  which  they  enclose. 
The  septum  becomes  partly  attached  to  the  arachnoid  externally,  and  partly 
spreads  laterally  over  the  inner  surface  of  that  membrane  (D).  The  septum  spreads 
internally  over  the  pial  sheath  as  the  epipial  subarachnoidal  tissue  (E),  forming 
numerous  small  spaces.  Two  vessels  may  be  observed  in  this  epipial  space. 
F,  the  posterior  nerve  roots,  surrounded  by  the  subarachnoidal  membranes. 
The  space  (I)  between  the  latter  membranes  and  the  septum  posticum  is  of 
variable  depth.  K  is  the  space  between  the  posterior  nerve  roots,  with  their 
membranes,  and  the  ligamentum  denticulatum ;  this  space  being  free  from 
membrane  throughout  the  entire  length  of  the  cord,  the  subarachnoidal  fluid 
finds  a  freer  passage  through  it  than  through  any  other  part  of  the  posterior 
subarachnoidal  space.  Anterior  to  the  ligamenta  denticulata  (G),  the  anterior 
subarachnoidal  space  may  be  observed  free  from  membrane.  H,  the  anterior 
nerve  roots. 


Fig.  101. 


ElG.  101  (From  Key  and  Eetzius).  Diagram  of  a  Transverse  Section  of  the  Spinal 
Cord  and  its  membranes,  showing  the  natural  size  and  relative  positions  of  the 
cord,  membranes,  and  spaces. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.  5 

is  a  meshwork  of  bundles  of  connective-tissue  fibres,  its  inner 
surface  being  lined  by  a  layer  of  endothelial  cells.  The  pia 
mater  contains  numerous  blood-vessels,  which  lie  between  the 
external  and  internal  layers,  whence  they  penetrate  into  the 
substance  of  the  cord  being  surrounded  by  a  prolongation  of  the 
pial  sheath. 

The  subarachnoidal  tissue  consists  of  a  plexus  of  trabeculse 
of  fibrous  connective  tissue  ensheathed  in  endothelium  and  con- 
taining a  few  elastic  fibres.  It  forms  a  spongy  tissue  between 
the  arachnoidal  and  pial  sheaths,  and  subdivides  the  subarach- 
noidal space  into  numerous  minute  lacunae.  It  is  a  prolongation 
of  the  inner  portion  of  the  arachnoid,  and  its  trabeculse  contain 
larger  and  smaller  blood-vessels. 

Ligainentum  denticulatum  stretches  like  a  diaphragm 
between  the  arachnoid  and  pial  sheaths  on  each  side  of  the 
cord,  from  the  foramen  ovale  magnum  down  to  the  filium  ter- 
minale,  between  the  anterior  and  posterior  nerve  roots.  The 
subarachnoidal  space  is  consequently  divided  into  an  anterior 
and  posterior  chamber.  The  ligamentum  denticulatum  consists 
of  trabeculse  of  connective-tissue  bundles,  the  trabeculse  being 
covered  with  endothelium.  The  tissue  passes  into  the  external 
layer  of  the  pia  mater  (Klein). 

Isolated  connective-tissue  trabeculse  also  extend  between  the 
dura  mater  and  arachnoid;  they  are  ensheathed  in  endothelium, 
while  blood-vessels  and  nerves  pass  from  the  one  membrane  to 
the  other.  These  trabeculas  are  most  numerous  in  the  posterior 
parts  of  the  cord. 

Between  the  dura  mater  and  arachnoid  is  the  subdural,  and 
between  the  arachnoid  and  pia  mater  is  the  subarachnoidal 
lymph  space.  Neither  of  these  spaces  form  one  open  and  free 
cavity,  inasmuch  as  numerous  connective-tissue  trabeculse  pass 
between  the  dura  mater  and  arachnoid,  and  between  the  latter 
and  pia  mater.  The  two  spaces  do  not,  however,  communicate 
with  one  another. 

The  nerve  roots  receive  a  prolongation  from  both  the 
arachnoidal  and  dural  sheaths,  and  consequently  the  lymph 
spaces  of  the  peripheral  nerves  and  their  ganglia  have  been 
injected  from  the  subarachnoidal  and  subdural  spaces  re- 
spectively (Key  and  Retzius). 


6  ANATOMICAL  AND   PHYSIOLOGICAL  INTEODUCTION, 

(II.)- STRUCTURE    OF    THE    SPINAL   COE,D   AND   MEDULLA 
OBLONGATA. 

The  spinal  cord  consists  of  a  framework,  with  grey  and  white 
matter  embedded  in  it. 

§  850.  The  framework  consists  of  the  following  parts  : — 

(1)  Connective-tissue  Processes. — Processes  of  fibrous  con- 
nective tissue  pass  from  the  intima  pise  into  the  anterior 
fissure,  and  at  different  points  of  the  circumference  of  the 
cord,  where  they  form  septa,  which  divide  the  white  columns  of 
the  cord  into  segments.  These  prolongations  of  the  intima 
pisD  carry  blood-vessels  into  the  cord. 

(2)  Neuroglia. — The  chief  part  of  the  framework  consists  of 
a  semi-fluid  substance  named  the  neuroglia-matrix.  This 
substance  presents  a  granular  aspect  under  certain  reagents, 
but  is  homogeneous  in  the  fresh  condition.  Numerous  minute 
fibrils,  which   anastomose  with  one  another  in  a  network,  are 


Fig.  102. 


Fig.  102  (From  Henle's  Anatomic).  Diagram  of  the  Spinal  Cord  and  its  Membranes. 
1,  the  dura  mater;  2,  the  arachnoid,  and  (3)  the  pia  mater;  4,  the  cortical 
layer  of  the  neuroglia. 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.  7 

embedded  in  this  substance.  These  fibrils  have  a  longitudinal 
direction,  except  in  the  septa,  where  they  form  transverse  net- 
works, and  in  the  grey  substance,  where  they  extend  uniformly 
in  all  directions  (Klein).  Flat,  branched,  nucleated  connective- 
tissue  corpuscles  are  found  in  connection  with  the  network  of 
the  neuroglia  fibrils.  The  neuroglia,  therefore,  is  composed  of 
neuroglia-matrix,  neuroglia  fibrils,  and  branched  cells,  the  latter 
being  named  Deiter's  cells  (Fig.  103). 

Fig.  103. 


Fig.  103  (From  Henle's  Anatomie).    Deiter's  Cdh. 


Didribution  of  the  Neuroglia. — The  neuroglia  is  abundant  in  the  fol- 
lowing parts  ; — 

(«)  On  the  external  surface  of  the  cord,  where  it  forms  a  peripheral 
crust  beneath  the  intima  piae,  the  latter  being  easily  separated  from  the 
former. 

{h)  In  the  septa  which  pass  between  different  sections  of  the  white 
matter ;  the  posterior  fissure  being,  indeed,  only  a  septum  of  this  kind 
(Klein). 

(c)  It  forms  the  ground  substance  of  the  anterior  and  posterior  nerve 
roots. 

(d)  A  layer  of  neuroglia  of  considerable  thickness  surrounds  the  epi- 
thelial lining  of  the  central  canal,  named  the  central  grey  nucleus  of 
KoUiker. 

(e)  A  peculiar  form  of  neuroglia  is  found  in  the  posterior  portion  of  the 
posterior  grey  horns  forming  the  substantia  gelatinosa  of  Eolando. 

The  neuroglia  is  always  more  abundant  near  the  grey  matter  and  in 
the  peripheral  crust  than  in  the  parts  between  them. 


8  ANATOMICAL   AND   PHYSIOLOGICAL   INTKODUCTION. 

§  351.  The  grey  '^natter  occupies  the  central  parts  of  the  cord 
in  the  well-known  shape  of  an  H.  The  median  part  contains  the 
central  canal,  and  the  "central  grey  nucleus"  of  Kolliker  the 
anterior  grey  and  white  commissures  lying  in  front  and  the  pos- 
terior commissure  behind  it.  The  lateral  parts  or  columns  con- 
sist of  an  anterior,  middle,  and  posterior  part ;  the  first  of  these 
representing  the  anterior,  and  the  last  the  posterior  grey 
horn;  while  the  middle  portion  on  each  side  of  the  central 
canal  consists  of  the  vesicular  column  of  Clarke,  and  what  may 
be  called  the  central  column.  The  central  grey  nucleus  of 
Kolliker  may  indeed  be  regarded  as  a  portion  of  the  central 
column. 

The  grey  matter  consists  of  a  (1)  matrix  of  neuroglia,  (2) 
ganglion  cells,  and  (3)  nerve  fibres. 

(1)  The  neuroglia  of  the  grey  matter  is  similar  to  that  of 
the  white.  It  is  looser  in  texture  and  more  spongy  in  the 
central  grey  column  than  in  either  the  anterior  or  posterior 
horns,  and  in  this  situation  it  also  contains  a  relatively  larger 
number  of  Deiter's  cells. 

(2)  The  ganglion  cells  of  the  anterior  horns  are  relatively 
large,  branched  cells,  containing  in  some  animals  masses  of 
yellow  pigment  ( §  13 ).  These  cells  are  surrounded  by  a 
lymph  space,  through  which  the  processes  of  the  cell  pass. 
The  ganglion  cells  of  the  posterior  horns  are  much  smaller  and 
less  branched  than  those  of  the  anterior  horns.  Some  of  the 
latter  appear  spiadle-shaped,  but  each  extremity  is  branched 
into  several  processes. 

(3)  The  nerve  fibres  of  the  grey  matter  are  of  different  kinds. 
The  great  bulk  of  the  grey  matter  is  composed  of  a  minute  and 
dense  network  of  fine  fibrils,  named  Gerlach's  nerve  network. 
The  nerve  network  surrounding  the  central  grey  nucleus  of 
Kolliker  is  less  dense  than  in  other  parts.  The  branched  pro- 
cesses of  the  ganglion  cell  attach  themselves  to  Gerlach's  nerve 
network;  while  the  unbranched  processes  pass  into  a  medul- 
lated  nerve  fibre  of  the  anterior  root.  The  cells  of  the  pos- 
terior horns  are  not  directly  connected  with  any  nerve  fibres, 
but  anastomose  with  them  indirectly  through  Gerlach's  nerve 
network  (Klein). 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


9 


§  352.  The  white  matter  is  composed  of  medullated  nerve 
fibres,  by  far  the  greater  number  being  arranged  in  a  longitudinal 
direction.  A  vertical  section  of  the  spinal  cord  is  represented  in 
Fig.  104,  showing  the  longitudinal  disposition  of  the  fibres  in 
the  anterior  and  lateral  columns.  Each  nerve  fibre  possesses 
an  axis  cylinder,  and  a  medullary  sheath,  but  there  is  no  definite 
evidence  of  the  presence  of  a  sheath  of  Schwann,  or  of  nerve 
corpuscles,  as  in  the  medullated  fibres  of  the  cerebro-spinal 
nerves.  The  nerve  fibres  are  embedded  in  neuroglia  as  pre- 
viously described ;  they  vary  much  in  size,  some  being  broad, 
some  of  medium  size,  while  others  are  very  fine. 

Fig.  104. 


rig.  104  (From  Henle's  Anatomie).— Fl,  Anterior  column;  Cga,  Anterior  grey 
horn ;  Fa,  Lateral  column  ;  Ca,  Posterior  grey  horn. 


The  white  matter  also  contains 
an  oblique  or  horizontal  direction, 
distinguished  : — 


nerve  fibres    that   have 
The  following  may  be 


(1)  The  fibres  of  the  posterior  roots  pass  into  the  grey  matter  of  the 
posterior  horns  as  horizontal  fibres.  These  fibres  on  entering  the  cord 
spread  out  laterally  in  the  form  of  a  fan,  so  that  an  external  fasciculus,  an 
internal  fasciculus,  and  a  median  portion  may  be  distinguished.  The 
fibres  of  the  external  fasciculus  wind  forwards  round  the  external  margin 
of  the  posterior  horn,  and  at  least  some  of  them  pass  forwards  through 
the  anterior  commissure,  a  few  even  passing  between  the  longitudinal 
fibres  of  the  anterior  column,  so  as  to  reach  the  internal  and  anterior 
groups  of  ganglion  cells  of  the  anterior  grey  horn  of  the  opposite  side 


10         ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

(Fig.  134,  p").  The  fibres  of  the  internal  fasciculus  pass  between  the 
longitudinal  fibres  of  the  posterior  root-zone  to  gain  the  posterior  horn 
{Fig.  134,  pr').  Some  of  them  then  wind  round  the  vesicular  column  of 
Clarke,  but  it  is  not  known  whether  they  are  connected  with  the  cells  of 
that  column.  A  few  of  these  fibres  appear  to  pass  behind  the  vesicular 
column  of  Clarke  and  to  decussate  with  the  corresponding  fibres  of  the 
opposite  side  in  the  posterior  commissure.  The  median  portion  of  the 
posterior  root  enters  the  white  matter  of  the  posterior  column,  and  its 
fibres  pass  for  a  longer  or  shorter  distance  iu  a  longitudinal  direction, 
either  upwards  or  downwards,  before  joining  the  posterior  grey  horns. 

(2)  The  medullated  nerve  fibres  of  the  anterior  nerve  roots  pass  in  an 
oblique  direction  from  the  grey  matter  of  the  anterior  horns  through  the 
white  matter. 

(3)  The  anterior  commissure  is  said  by  Gerlach  to  be  composed  of 
medullated  nerve  fibres  that  pass  from  the  grey  matter  of  the  anterior 
horn  of  one  side  into  the  white  matter  of  the  anterior  tract  of  the  oppo- 
site side.  Some  of  the  fibres,  however,  pass  from  the  anterior  horn  of  one 
side  to  the  pyramidal  tract  of  the  opposite  side,  while  others,  as  already 
described,  pass  from  the  internal  fasciculus  of  the  posterior  roots  of  one 
side  to  the  anterior  grey  horn  of  the  opposite  side. 

(4)  Medullated  nerve  fibres  emerge  from  the  sides  of  the  grey  matter 
of  the  anterior  horns,  and  after  a  short  course  enter  the  white  matter  of 
the  lateral  tracts  (Klein). 

(5)  Nerve  fibres  emerge  from  the  posterior  grey  horns,  and  after  a 
longer  or  shorter  horizontal  course  enter  the  white  matter  of  the  posterior 
column  (Gerlach).  It  is  probable  that  they  leave  the  posterior  tracts  again 
as  the  nerve  fibres  of  the  posterior  roots  (Klein). 

(6)  Fibres  emerge  from  the  cells  of  the  vesicular  column  of  Clarke,  which 
pass  obliquely  outwards  and  upwards  to  enter  the  direct  cerebellar  tract 
(Flechsig).  These  fibres  form  round  bundles  at  the  junction  of  the  grey 
substance  and  the  lateral  column,  and  are  cut  transversely  in  hori- 
zontal sections.  These  bundles  are  represented  in  Figs.  134  to  140  as 
dark  round  spots  near  the  formatio  reticularis  (fr). 

§  353.  Distribution  of  the  Vessels  of  the  Spinal  Cord, 
Medulla  Oblongata,  and  Pons. 

The  vertebral  artery  is  the  first  and  largest  branch  of  the  subclavian 
artery.  It  arises  from  the  posterior  aspect  of  the  trunk,  and  ascends 
through  the  foramina  in  the  transverse  processes  of  all  the  cervical  verte- 
brae, except  the  last.  It  winds  backwards  around  the  articulating  process 
of  the  atlas,  pierces  the  dura  mater,  enters  the  skull  through  the  foramen 
magnum,  and  terminates  at  the  lower  border  of  the  pons  Varolii  by  uniting 
with  the  corresponding  vessel  of  the  opposite  side  to  form  the  basilar  artery. 

The  basilar  artery  runs  forward  in  the  groove  on  the  anterior  surface  of 
the  pons  Varolii,  and  divides  at  the  anterior  border  of  the  pons  into  two 
terminal  branches,  one  to  either  side. 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION,  11 


Fig.  105. 


Fig.  105  (After  Duret).    Arteries  of  the  Medulla  Oblongata,  Pons,  and  Inferior 
Surface  of  the  Cerebellum. 

1,  Hoot  arteries  of  the  spinal  accessory  nerve. 

2,  Anterior  spinal  arteries. 

3,  Arteries  of  the  pneumogastric  and  glosso-pharyngeal  nerves. 

4,  Inferior  arteries  of  the  auditory  and  facial  nerves  (vertebral  branches). 

5,  Root  arteries  of  the  sixth  nerve. 

6  and  7,  Arteries  of  the  sub-olivary  fossa. 

8,  Superior  arteries  of  the  auditory  and  facial  nerves  (branches  of  the  middle 

cerebellar  artery). 

9,  Arteries  of  the  trigeminal  nerve. 

10,  Arteries  of  the  hypoglossal  nerve  (branches  of  the  vertebral  and  anterior 

spinal  arteries). 

A,  Inferior  cerebellar  artery. 

B,  Middle  cerebellar  artery. 

C,  Superior  cerebellar  artery. 

D,  Posterior  cerebral  artery. 

Branches.— The  branches  of  the  vertebral  and  basilar  artery  are  the 
following  : — 

Vertebral.  Basilar. 

Lateral  spinal,  Transverse, 

Muscular  branches,  Middle  cerebellar, 

Posterior  meningeal,  Superior  cerebellar. 

Anterior  spinal.  Posterior  cerebral. 
Posterior  spinal. 
Inferior  cerebellar. 


12 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


The  lateral  spinal  branches  enter  the  intervertebral  foramina,  and 
taking  the  course  of  the  roots  of  the  spinal  nerves,  are  distributed  to 
the  spinal  cord  and  vertebrae.  Where  the  vertebral  artery  curves  round 
the  articular  process  of  the  atlas,  it  gives  ofi"  several  muscular  branches. 

Tlie  posterior  meningeal  arteries  are  small  branches  which  enter  the 
cranium  through  the  foramen  magnum,  to  be  distributed  to  the  dura 
mater  of  the  cerebellar  fossae,  and  to  the  falx  cerebelli. 

Fig.  106. 


Fig.  106  (After  Duret).    Arteries  of  the  Pons  and  Medulla. 


1 1',  Anterior  spinal  artery,  the  bulbar 
branches. 

2  2'  2",  Inferior  arteries  of  the  pons. 

3  3",  Median  arteries  of  the  pons. 

4,  Superior  arteries  of  the  pons. 

5,  Posterior    spinal    arteries,    median 

branches. 


A,  Left  vertebral  artery. 

B,  Basilar  artery. 

C,  Middle  cerebellar  artery. 

D,  Superior  cerebellar  artery. 

E,  Posterior  cerebral  artery. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTEODUCTION. 


13 


Tha  anterior  spinal  artery  is  a  small  branch  which  unites  with  its 
fellow  of  the  opposite  side,  on  the  front  of  the  medulla  oblongata.  The 
artery  formed  by  the  union  of  these  two  vessels  descends  along  the 
anterior  aspect  of  the  spinal  cord,  to  which  it  distributes  branches,  and 
forms  the  commencement  of  the  anterior  median  artery. 

The  posterior  spinal  artery  winds  around  the  medulla  oblongata  to 
reach  the  posterior  aspect  of  the  cord,  and  descends  on  either  side  to 
the  Cauda  equina.  It  communicates  very  freely  with  the  spinal  branches 
of  the  intercostal  and  lumbar  arteries,  and  near  its  origin  sends  a  branch 
upwards  to  the  fourth  ventricle. 

The  inferior  cerebellar  arteries  wind  around  the  upper  part  of  the 
medulla  oblongata  to  reach  the  under  surface  of  the  cerebellum,  to  which 
they  are  distributed.  They  pass  between  the  filaments  of  origin  of  the 
hypoglossal  nerve  in  their  course,  and  anastomose  with  the  superior 
cerebellar  arteries.  Small  branches  derived  from  these  trunks  pass  to 
the  choroid  plexus  of  the  fourth  ventricle. 


Fig.  107  (After  Duret). 


Distribution  of  the  Arteries  on  the  Floor  of  the  Fourth 
Ventricle. 


A  A',  Posterior  spinal  artery. 

B  B',  Its  pyramidal  branches. 

C  C  C"  C",  Emergence  of  the  median  arteries. 

D  D',  Choroid  plexus  drawn  to  one  side.     (Two  or  three  arteries  may  be  seen 

to  emerge  from  it. ) 
E  E'  E"  E'",  Arteries  of   the  restiform   bodies    coming  from   the   inferior 

cerebellar  artery. 


14 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


The  transverse  branches  of  the  basilar  artery  supply  the  pons  Varolii, 
aud  adjacent  parts  of  the  brain. 

The  middle  cerebellar  artery  arises  from  the  trunk  of  the  basilar,  about 
its  middle.  It  runs  parallel  to  the  transverse  branches,  and  passes  along 
the  middle  peduncle  to  be  distributed  to  the  anterior  part  of  the  under 
surface  of  the  cerebellum.  It  gives  off  a  small  branch,  auditiva  interna, 
which  accompanies  the  auditory  nerve  into  the  meatus  auditorius  internus, 
and  to  the  labyrinth  of  the  ear.  The  auditory  branch  is  frequently  de- 
rived directly  from  the  basilar. 

The  superior  cerebellar  arteries  wind  around  the  crus  cerebri  on  each 
side,  lying  in  relation  with  the  fourth  nerve,  and  are  distributed  to  the 


Fig.  108  (After  Duiet) 


1  t    ies  of  the  Postenor  Part  of  the  Medulla  and  the 
Cerebellum, 


A,  Choroid  plexus.  B,  Choroid  velum.  C,  Posterior  openiDg, 

forming  a  communication  between  the  fourth  ventricle  and  the 
posterior  subarachnoid  space.  D,  Posterior  pyramid. 

1,  Inferior  cerebellar  artery. 

2  2",  Artery  of  the  choroid  plexus. 

3  3  3  3,  Arteries  of  the  choroid  velum.     Some  proceed   to  the  floor  of  the 

_  fourth  ventricle ;  they  are  capillary. 

5,  Posterior  spinal  artery. 

6,  Its  ascending  or  pyramidal  branch. 

7,  Its  descending  branch. 

8,  Its  median  branch. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.  15 

upper  surface  of  the  cerebellum  anastomosing  with  the  inferior  cerebellar. 
Branches  of  the  superior  cerebellar  arteries  run  inwards  to  supply  the 
valve  of  Vieussens  and  the  posterior  part  of  the  velum. 

The  ascending  cervical  branch  of  the  inferior  thyroid  artery  gives  off 
one  or  two  branches  {spinal  branches)  which  enter  the  intervertebral 
foramina  along  with  the  cervical  nerves,  and  assist  in  supplying  the  bodies 
of  the  vertebrae  and  the  spinal  cord  and  its  membranes. 

The  spinal  branches  of  the  aortic  intercostal  arteries  enter  the  inter- 
vertebral foramina  of  the  dorsal  region,  and  supply  the  vertebrae,  spinal 
cord,  and  membranes. 

The  spinal  branches  of  the  lumbar,  ilio-lumbar,  and  lateral  sacral  arteries 
enter  the  spinal  canal  through  the  intervertebral  foramina  ;  they  are  dis- 
tributed like  the  other  spinal  arteries,  and  anastomose  with  them. 

§  354.  The  following  arteries  are  distributed  to  the  medulla 
oblongata  and  pons" — 

1.  The  Root  Arteries. — These  arteries  are  directed  laterally  towards 
the  roots  of  the  nerves,  which  they  penetrate  near  their  point  of  emergence. 
They  subdivide  into  an  ascending  branch,  which  is  directed  towards  the 
nuclei  of  origin  of  the  nerves,  and  a  descending  branch  which  descends 
towards  the  periphery. 

(a)  Anterior  Root  Arteries  {Fig.  109,  ar). 

(1)  The  arteries  of  the  hypoglossal  nerve  are  derived  from  both 

the  anterior  spinal  and  vertebral  arteries. 

(2)  The  arteries  of  the  sixth  nerve  are  derived  from  the  basilar. 

(3)  The  arteries  of  the  third  nerve  are  derived  from  the  trunk 

of  the  basilar  near  its  termination. 

(6)  Lateral  Root  Arteries  {Fig.  109,  Ir). 

(1)  The  arteries  of  the  spinal  accessory  nerve  are  derived  from 

the  inferior  cerebellar  and  vertebral  arteries. 

(2)  The   arteries  of   the  pneumogastric  and  glosso-pharyngeal 

nerves  arise  from  the  vertebral  artery. 

(3)  The  arteries  of  the  auditory,  facial,  and  portio  intermedia 

(nerve  of  Wrisberg)  are  derived  from  the  vertebral  a  little 
before  its  termination,  and  from  a  branch  of  the  basilar. 
Branches  may  also  descend  perpendicularly  from  the  middle 
cerebellar  artery. 

(4)  The  artery  of  the  trigeminus  is  comparatively  large  and 

constant,  and  is  derived  directly  'from  the  basilar  about  its 
middle.  Another  branch  is  derived  from  the  middle 
cerebellar  artery. 

(5)  The  fourth  nerve,  as  well  as  the  optic  and  olfactory  nerves, 

receives  its  arterial  supply  from  the  branches  of  the  circle 
of  Willis. 


16         ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


Fig.  109.    Section  of  the  Medulla  Oblongata,  showing  the  Distribution  of  the  Vessels. 

E,  Artery  of  the  Median  Raph^. 

Ill,  Branches  to  the  formatio  reticularis. 
V,  Branch  to  the  olivary  body. 
1",  Branches  to  the  hypoglossal  nucleus. 

1'",        ,,  ,,       floor  of  the  fourth   ventricle,   and  to   the  internal 

inferior  nuclei  of  the  facial  {if), 
p,  Pyramidal  arteries. 
ar,  Anterior  root  artery  (hypoglossal). 
2',  Branch  to  olivary  body. 

2",  Branches  to  the  formatio  reticularis.    It  terminates  in  branches  to  the 
hypoglossal  nucleus. 
Ir,  Lateral  root  artery  (vagus). 

5,  Branch  to  the  restiform  body  and  the  inner  division  of  the  inferior 

cerebellar  peduncle. 
5',  Branches  to  the  nucleus  of  the  vagus.     Also  gives  branches  to  the 
ascending  root  of  the  fifth  and  the  formatio  reticularis. 


ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION.  17 


/ 


2.  Arteries  of  the  Median  Raphe  (Fig.  109,  R). 

(a)  Bulbar  arteries  derived  from  the  anterior  spinal  artery  (Fig.  106, 1). 

(b)  Inferior  arteries  of  the  pons  derived  from  the  lower  end  of  the 

basilar  (Fig.  106,  2  2'  2"), 

(c)  Median  arteries  of  the   pons,   derived  from  the  trunk  of  the 

basilar  (Fig.  106,  3  3"). 

(d)  Superior  arteries  of  the  pons,  derived  from  the  superior  end  of 

the  basilar  (Fig.  106,  4). 
The  annexed  diagram  (Fig.  110)  shows  that  a  double  row  of  vessels 
enter  the  Raphe,  the  vessels  on  each  side  of  th«  middle  line  entering  at 
different  levels.  A  vertical  section  of  the  olivary  body  shows  that  the 
vessels  enter  the  hilus  in  a  similar  manne.r  ;  so  that  the  branches  from 
the  anterior  root  artery  and  the  artery  of  the  Raphe  are  never  seen  in  the 
same  horizontal  section  as  represented  in  Fig.  109. 

3.  The  Lateral  Arteries  of  the  Medulla  Oblongata. 

(a)  Anterior  lateral  artery  (Fig.  109,  ala)  passes  into  the  substance  of 
the  medulla  behind  the  oHvary  body.     It  gives  branches  to  the 


ala,  The  anterior  lateral  artery  of  the  medulla  oblongata.  It  supplies 
branches  to  the  formatio  reticularis,  olivary  body,  anterior  nucleus 
of  the  lateral  column  [,alc),  and  terminates  in  branches  to  the  hypo- 
glossal nucleus. 

mla,  The  middle  lateral  artery  of  the  medulla  oblongata.  It  supplies 
branches  to  the  formatio  reticularis,  the  posterior  nucleus  of  the 
lateral  column  (pic),  and  terminates  in  branches  which  are  dis- 
tributed to  the  external  accessory  nucleus  of  the  facial  {ef). 

pla,  The  posterior  lateral  arteries  of  the  medulla  oblongata.    They  supply 
the  restiform  bodies. 
C,  Central  artery. 

3  3'  3",  Branches  to  the  hypoglossal  and  external  accessory  facial  nuclei. 
mp,  Median  posterior  artery. 

4  4'  4",   Branches  to  the  external    accessory  facial  and  pneumogastric 

nuclei. 
ep,  External  posterior  artery.     It  supplies  branches  to  the  internal  division 

of  the  inferior  peduncle  of  the  cerebelluma  and  restiform  body. 
i,  Internal  group  of  cells  of  the  hypoglossal  nucleus. 
al,  Antero-Jateral         ,,  ■       >■> 

pi,  Postero-lateral        ,,  ■     ,, 

a,  Anterior  ,,  ,, 

ale,  Anterior  nucleus  of  the  lateral  column. 
pic,  Posterior  ,,  ,, 

VIII,  Inferior  portion  of  the  posterior  median  acoustic  nucleus. 
if.  Internal  accessory  facial  nuclei. 
ef.  External  accessory  facial  nucleus. 
/,  Fasciculus  rotundus. 
XII,  Hypoglossal  nerve. 
X,  Pneumogastric  nerve. 
(t,  Column  of  GoU. 

pr,  Posterior  root-zone.      The  direct  cerebellar  tract  forms  a  thin  band  lying  ex- 
ternal to  the  column  of  Goll  and  posterior  root-zone. 
en,  Clavate  nucleus. 
tn.  Triangular  nucleus. 
0,  Olivary  body. 

po,  Parolivary  body. 
tip.  Nucleus  of  the  pyramid. 
pn.  Nucleus  of  the  arciform  fibres. 
P,  Anterior  pyramid. 


18 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


olivary  body,  the  anterior  lateral  nucleus,  and  terminates  between 
the  groups  of  ganglion  cells  of  the  hypoglossal  nerve. 

(6)  Middle,  lateral  artery  {Fig.  109,  mla)  passes  into  the  substance  of 
the  medulla  in  front  of  the  restiform  body.  It  gives  branches 
to  the  posterior  lateral  nucleus,  and  terminates  between  the  group 
of  cells,  which  give  origin  to  the  lateral  mixed  system  of  nerves. 

(c)  The  posterior  lateral  arteries  {Fig.  109,  pla)  enter  the  substance  of 
the  restiform  body  behind  the  roots  of  origin  of  the  mixed  lateral 
system  of  nerves. 

4.  The  Central  Artery  {Fig.  109,  c)  of  the  medulla  oblongata  is  a 
continuation  of  the  central  artery  of  the  spinal  cord.  It  subdivides  into 
internal,  middle,  and  external  branches  {Fig,  109,  3  3'  3")}  which  are 
distributed  betweea  the  groups  of  cells  of  the  hypoglossal  nucleus. 

5.  The  Median  Posterior  Artery  {Fig.  109,  mp)  enters  the  sub- 
stance of  the  medulla  oblongata  on  the  floor  of  the  fourth  ventricle.  It  is 
probably  derived  from  the  choroid  plexus.  It  is  mainly  distributed  to 
the  groups  of  cells  which  give  origin  to  the  nerves  of  the  lateral  mixed 
system. 

6.  The  External  Posterior  Artery  {Ftg.  109,  ep)  enters  the  sub- 
stance of  the  medulla  at  the  junction  of  the  grey  substance  with  the 
restiform  body. ' 

Fig.  110. 


Fig.  110   (From  Henle's  Anatomie).    Vertical  Section  of  Raphe  of  the  Medulla 
Oblongata,  showing  the  entrance  of  the  vessels. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


19 


§  355.  Arteries  of  the  Spinal  Cord. 
The  anterior  median  artery  gives  off  a  series  of  small  branches,  which  pass 
backwards  in  the  anterior  median  fissure,  and  reach  the  anterior  commis- 
sure, hence  these  vessels  may  be  called  the  arteries  of  the  anterior  median 
fissure  {Fig.  Ill,  aj).  Each  of  these  vessels  on  reaching  the  anterior  com- 
missure divides  into  two  main  trunks,  which  enter  the  grey  substance  of 
the  anterior  horns  j  these  may  be  called  the  arteries  of  the  anterior  com- 
missure {Fig.  Ill,  ac). 

Fig.  111. 


Fig.  111.  Diagram  of  the  Distribution 

Anterior  median  artery. 

af,  Arteries  of  the  anterior  median 
fissure. 

ac,  Artery  of  the  anterior  commis- 
sure. 

1,  Anterior  branch. 
1'.  Median  branch. 

1  ,  Posterior  branch. 
ca,  Central  artery. 

2,  Anterior  branch. 
2',  Median  branch. 
2",  Posterior  branch. 

pa.  Posterior  root  arteries. 
6  6  6",  Arteries  of  posterior  horns. 
ia,  Internal  anterior  root  arter}'. 
ea,  External  anterior  root  artery. 
3  3',  Internal  and  external  branch. 


of  tht  Blood-vessels  in  the  Sjnnal  Cord. 

ar,  Anterp-lateral  branch. 

4,  Anterior  branch. 

4',  Median  branch. 

4",  Posterior  branch. 

mr,  Median  lateral  artery. 

5  5',  Anterior  and  posterior  branches. 
pr,  Posterior  lateral  arteries. 
ip,  Internal  posterior  artery. 
mj),  External  posterior  artery. 

g,  Arteries  of  the  column  of  Goll. 
PC  Artery  of  the  posterior  commissure. 
fC,  Vesicular  column  of  Clarke. 
t,  Internal  group  of  cells. 
a,  Anterior  group. 
al,  Antero-lateral  group. 
pi,  Postero-lateral  group, 
c,  Central  group. 
m,  Median  area. 


20  ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

The  artery  of  the  anterior  commissure  subdivides  into  three  branches, 
■which,  from  their  position,  may  respectively  be  named  the  anterior 
{Fig.  Ill,  1),  median  {Fig.  Ill,  1'),  and  posterior  {Fig.  Ill,  1")  branches. 
The  anterior  branch  curves  forwards,  and  is  distributed  to  the  anterior 
and  internal  portion  of  the  grey  substance ;  the  median  is  distributed  to 
the  lateral  portion  of  the  anterior  horn,  while  the  posterior  is  directed 
backwards  to  the  posterior  horn. 

The  central  artery  also  gives  off  an  anterior  {Fig.  Ill,  2),  median 
{Fig.  Ill,  2'),  and  posterior  {Fig.  Ill,  2")  branch,  which  are  distributed 
respectively  to  the  anterior,  lateral,  and  posterior  portions  of  the  grey 
substance.  The  median  branches  of  the  two  main  vessels,  besides  sup- 
plying the  grey  substance,  are  also  distributed  to  the  pyramidal  tract  of 
the  lateral  column. 

Tlie  posterior  spinal  artery  {Fig.  Ill,  pa)  gives  off  branches,  which 
pass  by  the  side  of  the  posterior  roots  to  enter  the  grey  substance  of  the 
posterior  horns,  where  they  subdivide  into  a  variable  number  of  small 
branches  {Fig.  Ill,  6  6'  6"),  which  may  be  called  arteries  of  the  posterior 
horns.  In  addition  to  the  vessels  just  described,  a  large  number  pass  from 
the  pia  mater  into  the  substance  of  the  cord,  and  some  of  these  are  so 
large  and  so  constant  as  to  deserve  special  mention  ;  two  run  by  the  side 
of  the  bundles  of  fibres  which  constitute  the  anterior  roots  of  the  nerves, 
hence  they  may  be  called  the  anterior  root  arteries.  The  branch  nearest 
the  median  fissure  may  be  called  the  internal  anterior  root  {Fig,  111,  ia), 
and  the  other  the  external  anterior  root  {Fig.  lll.^a)  artery. 

The  internal  anterior  root  artery  {Fig.  Ill,  ia),  on  entering  the  grey 
substance,  joins  the  anterior  branches  of  the  first  subdivision  of  the  artery 
of  the  anterior  median  fissure  and  of  the  central  artery. 

The  external  anterior  root  artery  {Fig.  Ill,  ea),  on  entering  the  grey 
substance,  subdivides  into  two  branches,  the  inner  {Fig.  Ill,  3)  of  which 
is  distributed  along  with  the  vessels  just  mentioned  ;  while  the  outer 
branch  {Fig.  Ill,  3'^  passes  between  what  we  may  call  the  antero-lateral 
{Fig.  Ill,  al)  and  central  groups  {Fig.  Ill,  c)  of  cells. 

A  very  constant  vessel  passes  to  the  grey  substance  from  the  pia  mater, 
at  the  point  of  junction  of  the  anterior  and  lateral  columns  of  the  cord, 
and  it  may  therefore  be  called  the  antero-lateral  artery  {Fig.  Ill,  ar).  On 
reaching  the  grey  substance  it  frequently  divides  into  three  branches,  one 
of  which  passes  in  front  {Fig.  Ill,  ar,  4  4'  4"),  another  behind,  and  another 
into  the  substance  of  the  antero-lateral  group  of  cells.  Another  constant 
vessel  {Fig.  Ill,  mr)  passes  from  the  lateral  aspect  of  the  cord,  and  on 
reaching  the  grey  substance  it  subdivides  into  two  branches,  the  one  of 
which  passes  in  front  and  the  other  behind  the  postero-lateral  group  of 
cells  {Fig.  Ml,  pi),  and  this  vessel  may  from  its  position  be  called  the 
median-lateral  artery.  Small  branches  {Fig.  Ill,  jor)  pass  at  short  inter- 
vals through  the  posterior  part  of  the  lateral  column,  and,  together  with 
the  median  branches  of  the  first  subdivision  of  the  artery  of  the  anterior 
median  fissure,  and  of  the  central  arteries,  supply  the  posterior  part  of 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.  21 

the  lateral  columns ;  hence  these  vessels  may  be  called  posterior  lateral 
arteries. 

Two  vessels  pass  from  the  pia  mater  into  the  substance  of  the  posterior 
column  ;  the  one  nearest  the  posterior  median  fissure,  and  which  may 
therefore  be  called  the  internal  posterior  artery  {Fig.  Ill,  ip),  passes 
between  the  column  of  Goll  and  the  posterior  root-zone ;  and  after  passing 
through  about  two-thirds  of  the  depth  of  the  posterior  column,  it  curves 
outwards  to  reach  the  posterior  grey  horn.  The  other  vessel  may  be 
named  the  external  or  median  posterior  artery  {Fig.  Ill,  mp) ;  it  passes 
into  the  substance  of  the  posterior  column  at  the  middle  of  the  posterior 
root-zone,  and  on  reaching  about  one-third  the  depth  of  the  posterior 
column,  it  curves  outwards  to  reach  the  posterior  grey  horn,  where 
it  terminates.  Small  vessels  {Fig.  Ill,  g)  pass  from  the  pia  mater  of 
the  posterior  median  fissure  into  the  substance  of  the  column  of  Goll. 
Another  vessel,  which  may  be  called  the  artery  of  the  posterior  commissure 
{Fig.  1 11,  pc),  passes  from  the  pia  mater  along  the  posterior  margin  of  the 
posterior  commissure,  and  winds  backwards  along  the  internal  edge  of  the 
posterior  horn. 

§  356.  Growuing  of  the  Ganglion  Cells. — The  ganglion  cells 
of  the  anterior  horns  are  arranged  in  groups  which  are  pretty 
constant  for  the  same  portions  of  the  cord,  although  the 
arrangement  varies  considerably  when  sections  at  different 
elevations  are  compared.  A  diagram  of  the  topographical 
distribution  of  these  groups  is  given  in  Fig.  Ill,  Beginning 
at  the  posterior  and  lateral  aspect  of  the  anterior  horn, 
a  group  is  observed  which  from  its  position  is  called  the 
postero-lateral  group  (pi).  It  is  bounded  behind  by  the  pos- 
terior and  in  front  by  the  anterior  twig  of  the  median  branch 
of  the  central  artery ;  while  on  its  external  aspect  it  receives 
branches  from  the  median  lateral  artery,  one  of  which  passes 
behind  and  another  in  front  of  it.  Anterior  to  this  group  is 
another,  which  from  its  position  is  called  the  antero-lateral 
group  (al).  On  its  external  aspect  the  group  receives  branches 
from  the  anterior  lateral  artery,  one  of  these  passing  behind 
and  another  in  front  of  it,  while  a  median  branch  of  the  artery 
may  often  be  seen  to  pass  into  its  substance.  A  branch  from 
the  external  anterior  root  artery  winds  round  its  inner  border 
to  gain  the  posterior  aspect ;  while  the  anterior  branch  of  the 
central  artery  passes  along  its  internal  and  anterior  aspects. 

It  has  already  been  mentioned  that  the  internal  and  external 
anterior  root  arteries,  on  reaching  the  grey  substance,  divide 


22         ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

into  two  branches;  and  the  external  branch  of  the  former  and 
internal  of  the  latter  converge  so  as  to  meet  at  a  point  like  the 
limbs  of  the  letter  V.  In  the  small  area  of  grey  matter  which 
lies  between  these  vessels  several  distinct  cells  are  so  constantly 
observed  as  to  deserve  a  special  name.  These  cells  may  from 
their  position  be  called  the  anterior  group  (a).  Another  group 
of  large  cells,  which  may  be  called  the  internal  growp  {i),  is 
bounded  anteriorly  and  internally  by  white  substance,  and  on 
the  external  aspect  by  the  anterior  branch  of  the  first  subdivision 
of  the  artery  of  the  anterior  median  fissure.  Another  group  of 
cells  may  be  observed  towards  the  centre  of  the  anterior  horns, 
and  it  may  therefore  be  termed  the  central  group  (c).  It  is 
bounded  in  front  and  on  its  internal  and  external  borders  by 
the  external  and  internal  branches  of  the  external  anterior 
root  artery ;  and  behind  and  also  on  its  internal  border  by  the 
median  and  anterior  branches  of  the  central  artery.  A  very 
important  area  lies  between  the  internal  group  on  the  one 
hand  and  the  antero-lateral  and  central  groups  on  the  other, 
while  the  anterior  group  passes  into  its  anterior  border,  like 
a  small  wedgfe,  so  as  to  divide  it  into  the  form  of  the  letter  Y. 
The  cells  of  this  median  area  (m)  are  much  smaller  than  those 
of  the  other  groups,  and  the  area  itself  is  exceedingly  vascular, 
being  supplied  by  the  two  anterior  root  arteries^  the  anterior 
branch  of  the  first  division  of  the  artery  of  the  anterior  median 
fissure,  and  the  anterior  branch  of  the  central  artery.  A  final 
group  of  cells  lies  near  the  internal  border  of  the  posterior 
grey  horn  near  the  posterior  commissure  called  the  vesicular 
column  of  Clarke  {vc).  We  must  again  direct  attention  to  the 
fact  i\iQ,i  Fig.  Ill  is  only  a  diagram;  and  although  it  is  more  like 
the  upper  part  of  the  lumbar  and  lower  portion  of  the  cervical 
enlargements  than  any  other  part  of  the  cord,  yet  it  is  not  a 
strictly  accurate  representation  of  any  one  section.  The  dis- 
tribution of  these  groups  at  various  elevations  of  the  cord  will 
be  better  understood  after  the  history  of  the  development  of 
the  grey  substance  has  been  sketched. 

§  357.  Development  of  the  Central  Grey  Tube. 

The  parts  which  subsequently  correspond  to  the  anterior  grey  horns 
are  the  first  portions  of  the  cord  to  be  developed.     These  are  soon  sue- 


ANATOMICAL   AND   PHYSIOLOGICAL   INTKODUCTION. 


23 


ceeded  hy  lateral  masses,  and  somewhat  later  by  the  posterior  horns.  The 
anterior  grey  commissure  is  then  formed,  and  this  is  soon  followed  by  the 
development  of  the  posterior  commissure,  and  it  is  only  at  a  considerably 
later  period  that  the  white  commissure  appears.  When  the  tube  which 
forms  the  rudiment  of  the  cord  has  closed,  it  is  seen  to  be  somewhat  oval 
on  section,  and  at  this  period  it  consists  almost  entirely  of  grey  substance. 
The  grey  substance  is  at  first  composed  of  small  round  cells,  not 
much  larger  than  lymphoid  corpuscles,  with  a  distinct  nucleus,  and  no 
difference  can  be  detected  between  one  portion  and  another ;  the  whole 
is  simple  and  indefinite  in  its  structure.  A  section  of  the  cord  at  the 
third  month  of  embryonic  life  {Fi^.  112)  shows  that  the  central  canal  has 
contracted  to  a  small  oval  opening,  covered  by  columnar  epithelium,  while 
the  grey  substance  has  assumed  the  general  outline  characteristic  of  the 
grey  substance  of  the  adult  cord.  The  grey  substance  is  also  surrounded 
by  a  mantle  of  white  substance,  but  we  shall  entirely  neglect  the  history 
of  the  development  of  the  latter  in  the  meantime. 


Fig.  112. 


§  358.  Development  of  the  Anterior  Orey  Horns. 
The  most  noticeable  feature  about  the  grey  substance  at  the  third 
month  is  that  the  anterior  grey  horns  are  distinctly  differentiated  from 
the  posterior  horns,  not  simply  in  their  general  outline,  but  in  their 
intimate  structure.  The  groups  of  gan- 
glion cells  are  now  beginning  to  be 
distinctly  recognisable.  Of  these,  the 
antero-lateral  group  is  the  most  advanced 
in  its  development.  Large,  mostly  round, 
cells,  with  a  distinct  nucleus,  are  observed 
embedded  in  the  embryonic  tissue  ;  but 
the  cells  have  not  yet  assumed  distinct 
processes.  The  small  internal  group  is 
also  well  represented  by  several  distinct 
large  cells,  but  the  cells  are  more  elon- 
gated, and  not  quite  so  large  or  so  distinct 
as  in  the  antero-lateral  group.  A  few  cells 
may  be  observed  in  the  anterior  group. 
The  postero-lateral  group  is  represented 
by  four  or  five  large  round  cells,  but  the 
central  group  is  not  yet  represented.  The 
areas  in  which  the  median  and  central 
groups  are  subsequently  developed,  and 
the  area  which  separates  the  antero-lateral 
and  postero-lateral  groups,  are  composed  entirely  of  embryonic  tissue, 
with  small  round  cells.  The  vesicular  column  of  Clarke  can  also  be 
distinguished  at  this  period,  by  a  slight  increase  in  the  size  of  the  cells  in 
comparison  with  those  of  the  surrounding  tissue,  but  the  group  does  not 
appear  in  the  portion  of  the  cord  from  which  this  section  was  taken. 


Fig.  112.  Section  from  the  middle 
of  the  Cervical  Enlargement  of 
the  Spinal  Cord  at  the  third  month 
of  Embryonic  Life. — C,  Central 
canal.  The  other  letters  indicate 
the  same  as  the  corresponding 
letters  in  Fig.  111. 


24 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


A  still  further  advance  in  development  is  recognisable  at  the  end  of  the 
fifth  month  of  embryonic  life  (Figs.  113  and  1 14),  The  cells  of  the  antero- 
lateral group  have  not  only  increased  still  further  in  size,  but  their  pro- 
cesses are  now  well  developed  {.Fig.  114, 1),  and  each  may  be  seen  to  lie  in  a 
distinct  cavity.  Those  of  the  anterior  and  internal  groups  are  also  well 
developed,  and  the  same  may  be  said  with  respect  to  the  cells  of  the  centre 
of  the  postero-lateral  group  ;  and  even  those  of  the  central  group  are 
fairly  well  developed,  although  only  two  or  three  of  them  have  as  yet 
developed  processes.  The  area  in  which  the  median  group  is  subsequently 
developed,  and  the  margins  of  the  postero-lateral  and  central  groups  still 
consist  of  embryonic  tissue.  The  larger  cells  of  these  areas  are  represented 
inFig.  114,  2.  The  section  represented  in  Fig.  113  was  taken  from  the 
middle  of  the  cervical  enlargement,  and  the  vesicular  column  of  Clarke  is 
not  represented  ;  but  the  cells  of  this  column  are  fairly  well  developed  at 
the  fifth  month  in  the  lower  end  of  the  cervical  enlargement  and  in  the 
dorsal  region  and  upper  end  of  the  lumbar  enlargement.  The  section  repre- 
sented in  Fig.  114  was  taken  from  the  middle  of  the  lumbar  enlargement, 
and  no  trace  of  the  postero-lateral  group  could  be  discovered  ;  but  in  the 
upper  portion  of  the  lumbar  enlargement  it  occupies  a  similar  position  to 


Fig,  113. 


Fia.  114. 


I.*"^     ®  2 


EiGS.  113  and  114  (Young).  Sections  of  Spinal  Cord  of  a  Five  Months  Human 
Embryo,  from  the  middle  of  the  cervical  and  lumbar  enlargements  respec- 
tively.—  i,  internal;  a,  anterior;  al,  antero-lateral ;  pi,  postero-lateral, 
c,  central,  m,  median,  and  groups  of  ganglion  cells  :  1,  ganglion  cell  of  the 
centre  of  the  antero-lateral  group  ;   2,  ganglion  cell  of  median  group 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 


25 


that  which  it  occupies  in  the  cervical  enlargement,  as  represented  in 
Fig.  113.  The  vesicular  column  of  Clarke  does  not  appear  in  the  lumbar 
enlargement. 

The  ganglion  cells  of  the  various  groups  have  become  still  further  deve- 
loped at  the  ninth  month  {Figs.  115  and  116) ;  while  by  the  development 


Fig.  115. 


Fia.  116. 


f3ic 


Figs.  115  and  116  (Young).  Sections  of  Spinal  Cord  of  a  Nine  Months  Human 
Embryo,  from  the  middle  of  the  lumbar  and  cervical  enlargements  respec- 
tively.— A,  anterior,  and  P,  posterior  horns.  The  small  letters  indicate  the 
same  as  in  Figs.  113  and  114.  The  normal  size  of  the  section  from  which 
the  drawing  was  made  is  shown  above  each  figure. 


of  caudate  cells  in  the  central  and  postero-lateral  groups  the  various 
groups  have  became  so  approximated  as  not  to  be  so  distinctly  recog- 
nisable from  each  other  as  they  were  at  the  fifth  month  of  embryonic 
■life.  The  section  represented  in  Fig.  115  was  taken  from  the  middle  of  the 
lumbar  enlargement,  and  the  postero-lateral  group  is  not  so  well  repre- 
sented as  it  is  in  the  upper  part  of  the  lumbar  region.  The  median  area 
now  contains  distinct  ganglion  cells  instead  of  consisting  entirely  of  em- 
bryonic tissue.  These  cells  are,  however,  not  much  larger  than  those  of 
the  antero-lateral  group  at  the  third  month  ;  while  they  are  by  no  means 
so  well  developed  as  those  of  the  latter  at  the  fifth  month.  The  cells  of 
the  median  group  are  small,  angular  masses  with  a  distinct  nucleus,  but 
only  a  relatively  small  number  of  these  have  developed  processes.  It  is 
not  necessary  to  say  much  at  present  with  respect  to  the  adult  cord.  The 
most  noticeable  feature  in  which  the  cervical  and  lumbar  enlargements  of 
the  adult  cord  differ  from  the  corresponding  parts  of  the  cord  of  a  nine 


26  ANATOMICAL  AND  PHYSIOLOGICAL   INTEODUCTION. 

months  embi'jo  is  in  the  fact  that  the  ganghon  cells  of  the  median  group 
have  developed  processes  like  those  of  the  other  groups.  The  cells  of  the 
median  group,  however,  especially  in  the  cervical  enlargement,  are  not 
only  much  smaller  than  those  of  the  other  groups,  but  they  are  much 
thinner  and  more  transparent.  These  cells  are  so  transparent  that  they 
may  be  very  readily  overlooked  altogether  in  sections  cleared  by  oil  of 
cloves,  and  mounted  in  Canada  balsam  ;  while  the  cells  of  the  antero- 
lateral group  not  only  intercept  the  light,  but  require  considerable  change 
of  focus,  in  order  to  bring  their  anterior  and  posterior  surfaces  clearly 
into  view. 

The  relationship  which  the  developing  cells  bear  to  the  distribution  of 
the  blood-vessels  is  exceedingly  interesting.  The  earlier-developed  cells 
appear  to  be  thrust  further  and  further  away  from  the  vessels  as  develop- 
ment advances.  The  postero-lateral  group,  for  instance,  first  shows  itself 
by  the  development  of  four  or  five  large  cells,  which  appear  about  the 
centre  of  the  spot  in  which  the  completed  group  is  subsequently  situated  ; 
and,  as  ganglion  cell  after  ganglion  cell  becomes  developed  around  this 
centre,  the  area  becomes  increased  in  size  by  the  growth  of  additional 
embryonic  tissue  around  the  circumference  of  the  group  in  the  part 
which  is  in  relation  with  the  arterioles  (Fig.  111).  The  ganglion  cells  of 
the  centre  of  the  group  are  the  first  to  be  developed,  and  the  group 
increases  in  size  by  the  gradual  development  of  new  cells  around  the 
central  ones.  The  marginal  cells  of  the  group  are  consequently  the  last 
to  be  developed.  Similar  remarks  apply  to  the  ganglion  cells  of  the 
central  group,  as  well  as  to  the  antero-lateral,  anterior,  and  internal 
groups,  except  that  the  last  three  groups,  instead  of  being  surrounded  on 
all  sides  by  grey  substance,  are  on  one  of  their  sides  in  contact  with 
white  substance. 

§  359.  The  Accessory  Nerve  Nuclei  of  the  Spinal  Cord. 
(1)  Median  Area. — The  comparatively  late  period  in  the  development  of 
the  cord  at  which  the  ganglion  cells  of  the  median  area  of  the  anterior  horns 
assume  processes  shows  that  this  area  must  be  regarded  as  an  accessory 
structure  (§  33).  The  relatively  large  size  of  this  area  in  the  cervical,  as 
compared  with  the  lumbar  enlargement,  shows  that  it  is  a  much  more  im- 
portant structure  in  the  former  than  the  latter  region.  In  the  fifth  month 
of  embryonic  life  the  median  area  is  not  larger  in  the  cervical  than  in  the 
lumbar  region,  as  shown  in  Figs.  113  and  114,  where  it  will  be  seen  that  there 
is  scarcely  any  difference  in  the  general  outline  of  the  anterior  horns  in  the 
sections  from  the  middle  of  the  cervical  and  lumbar  enlargements  respec- 
tively. In  the  embryo  of  the  ninth  month,  however,  the  median  area  in 
the  cervical  is  decidedly  larger  than  in  the  lumbar  enlargement  {Figs.  115 
and  116),  and  consequently  the  anterior  grey  horn  in  the  former  region 
is  extended  laterally  to  make  room  for  this  area.  The  relative  increase  in 
the  size  of  the  median  area  in  the  cervical  enlargement  of  the  human 
adult  cord,  as  compared  with  that  of  the  lumbar  enlargement,  is  still  more 


ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 


27 


marked  than  in  the  cord  of  a  nine  months  embryo,  as  may  be  seen  in 
Figs.  117  and  118,  where  the  median  area  occupies  a  large  space,  and  the 
lateral  outgrowth  of  the  anterior  grey  horn  of  the  cervical  region  is  very 
decided. 

On  observing  the  large  relative  size  of  the  median  area  in  the  cervical 
enlargement  of  the  adult  human  cord,  as  compared  with  that  of  the  lumbar 
enlargement,  and  even  as  compared  with  that  of  the  cervical  enlargement 
of  the  cord  of  the  embryo,  it  occurred  to  me  that  this  area  might  not 


Fig.  117. 


Fig.  118. 


Figs.  117  and  118  (Young\  Sections  of  the  Adult  Spinal  Cord  from  the  middle  of 
the  Lumbar  and  Cervical  Enlargements  respectively. — The  letters  indicate  the 
same  as  those  in  Figs.  113  and  ll4. 

possess  any  relative  importance  in  the  cervical  enlargement  of  the  spinal 
cord  in  animals.  In  order  to  test  this  conclusion  I  applied  to  Mr.  Larmuth, 
of  the  Owens  College,  whose' beautiful  sections  of  the  spinal  cord  are  well 
known  in  Manchester,  and  asked  him  if  he  would  be  kind  enough  to  let 
me  have  sections  of  the  lumbar  and  cervical  enlargements,  as  well  as 
from  the  middle  of  the  dorsal  region  and  the  upper  portion  of  the  cer- 
vical region  of  the  spinal  cord  of  the  ox.  Mr.  Larmuth,  in  kindly  con- 
senting to  let  me  have  what  I  wanted,  volunteered  the  statement  that 
it  was  quite  unnecessary  to  have  a  section  of  both  the  cervical  and  lumbar 
regions,  as  the  two  were  so  alike  as  to  be  indistinguishable,  and  both  were 
like  the  lumbar  enlargement  of  the  human  cord.  This  was,  to  a  large 
extent,  the  very  fact  I  was  in  search  of.  I  have  had  an  opportunity 
since  that  time  of  examining  these  sections  more  minutely  A  section 
from  the  cervical  enlargement  of  a  calf  is  represented  in  Fig.  119,  and  it 


28 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


will  be  at  once  seen  that  the  general  outline  of  the  grey  substance  is 
very  like  that  of  the  grey  substance  of  the  lumbar  enlargement  in  man, 
and  the  median  area  occupies  a  still  smaller  area  in  the  former  than  in 
the  latter.  The  median  area,  indeed,  can  scarcely  be  said  to  exist  in 
the  spinal  cord  of  the  calf,  and  this  is  also  true  with  respect  to  the  cord 
of  the  ox. 

(2)  The,  medio-lateral  area  lies  between  the  antero-lateral  and  postero- 
lateral groups  of  ganglion  cells,  and  it  will  be  hereafter  seen  that  it  is  a 
very  important  structure  in  the  dorsal  and  upper  cervical  regions  of  the 
cord  {Figs.  120  and  121,  ml).  The  cells  of  this  area  are  not  well 
developed  at  the  ninth  month  of  embryonic  life  in  these  regions  of  the 
cord,  and  it  is  entirely  unrepresented  in  the  spinal  cords  of  the  ox  and  dog. 

Fig.  119. 


Fig.  119  (Young).    Section  of  Cervical  Enlargement  of  Calf.- 
the  same  as  Fig.  113. 


-The  letters  indicate 


We  have  just  noticed  that  the  cells  of  the  median  and  medio-lateral 
areas  are  not  only  developed  at  a  comparatively  late  period  of  embryonic 
life,  but  that  they  are  also  much  smaller  in  size  than  those  of  the  other 
groups  of  the  anterior  horns.  It  might,  therefore,  be  concluded  that  the 
size  of  a  ganglion  cell  may  be  accepted  as  a  true  test  of  the  time  at  which 
it  began  to  develop.  This  test  can,  however,  be  relied  upon  only  within 
certain  very  narrow  limits.     The  cells  at  the  margins  of  the  postero- 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.  29 

lateral  group  in  the  lumbar  and  cervical  enlargements  are  nearly  if 
not  quite  as  large  as  those  of  the  centre  of  the  group,  although  the 
latter  began  to  develoj)  at  a  much  earlier  period  than  the  former  ;  while 
the  cells  of  the  nuclei  of  origin  of  the  third  and  fourth  nerves  are  small, 
although  they  have  begun  to  develop  at  a  comparatively  early  period. 
The  size  of  the  cell  may  be  accepted  as  a  rough  test  of  its  age  during  the 
period  of  development,  and  no  longer,  just  as  the  size  of  a  growing 
human  being  may  be  accepted  as  a  rough  test  of  age  until  the  adult 
condition  is  attained,  when  it  ceases  to  be  a  test  any  longer.  The 
size  of  the  ganglion  cells  of  the  anterior  horns  of  the  cord  of  the 
adult  appears  to  depend  mainly  if  not  entirely  upon  the  size  of  the 
muscle  over  whose  function  it  presides  ;  hence  the  cells  of  the  nuclei  of 
the  third  and  fourth  nerves  are  small,  while  the  greater  number  of  the 
cells  of  the  cervical  enlargement  are  large,  and  those  of  the  lumbar 
enlargement  are  still  larger.  It  frequently  happens  that  the  later- 
developed  cells  of  the  cord  are  small  in  the  adult  condition,  but  this  is 
because  the  most  special  muscular  adjustments  are  effected  by  the  con- 
tractions of  small  muscles. 

§  360.  Development  of  the  Neuroglia. 

So  far  we  have  spoken  only  of  the  development  of  the  ganglion 
cells,  but  we  must  now  briefly  refer  to  that  of  the  neuroglia.  In  the 
early  weeks  of  foetal  life  the  neuroglia  consists  of  small  round  nucleated 
cells,  or  rather  of  a  nucleus  surrounded  by  a  layer  of  soft  protoplasm,  and 
with  scarcely  a  trace  of  basis  substance.  As  development  advances, 
the  protoplasm  contracts  round  the  nuclei,  and  the  latter  become 
embedded  in  a  fibrillated,  some  say  granular  basis  substance.  The 
neuroglia  becomes  denser  and  more  compact  in  proportion  as  it  acquires 
more  and  more  of  the  basis  substance  and  loses  its  cellular  character. 
This  change  does  not  occur  in  every  part  of  the  grey  substance  at  the 
same  time.  Speaking  broadly,  the  neuroglia  assumes  a  fibrillated  texture 
in  the  very  portions  of  which  the  ganglion  cells  are  earliest  developed ; 
while  it  maintains  its  embryonic  condition  in  the  margins  of  the 
groups  of  ganglion  cells  of  the  anterior  horns  and  along  the  line  of  the 
blood-vessels.  And  when  a  section  of  the  adult  cord  is  held  up  to  the 
light  the  groups  of  large  ganglion  cells  may  be  seen  as  dark  spots  inter- 
cepting the  light,  and  strongly  contrasting  with  the  transparency  of  the 
median  area  and  of  the  margins  of  the  antero-lateral  and  postero-lateral 
groups  along  the  lines  of  the  vessels.  The  transparent  portion  also  em- 
braces the  anterior  and  posterior  grey  commissures  and  the  central  column 
of  the  grey  substance  as  far  back  as  the  substantia  gelatinosa,  with  the 
exception  of  the  area  occupied  by  the  vesicular  column  of  Clarke.  The 
transparency  of  the  area  just  described  is  no  doubt  due  in  some  measure 
to  the  fact  that  the  small  ganglion  cells  themselves  are  more  transparent 
than  the  large  ganglion  cells,  but  it  is  also  in  great  measure  due  to  the 
loose  and  spongy  character  of  the  neuroglia  in  the  former  areas  as  com- 


30  ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 

pared  with  the  compact  and  fibrillated  texture  of  the  neixroglia  surrounding 
the  ganglion  cells  of  the  earlier-developed  groups.  The  transparency  is 
increased  by  the  fact  that  the  larger  vessels  of  the  anterior  horns  pass 
along  the  transparent  areas,  while  only  the  smaller  vessels  pass  into  the 
substance  of  the  earlier-developed  groups. 

§  361.  Development  of  the  Posterior  Orey  Horns 

The  development  of  the  posterior  horns  appears  to  proceed  on  a  dif- 
ferent principle  from  that  of  the  anterior  horns.  The  vessel  which  is 
mainly  distributed  to  the  posterior  horn  passes  into  it  through  the  centre 
of  the  posterior  roots  of  the  nerves,  and  the  development  of  new  substance 
proceeds  mainly  in  the  centre  of  the  horn,  so  that  the  older-formed  tissue 
is  pushed  out  laterally.  The  central  portion  of  the  horn  consists  of  what 
is  called  the  substantia  gelatinosa,  and  is  made  up  in  large  part  of  neu- 
roglia and  fibrils,  in  which  medium-sized  ganglion  cells  are  embedded. 
The  lateral  portions  of  the  horn  contain  well-formed  and  thicker  nerve 
fibres.  The  most  internal  of  these  fibres  pass  through  the  posterior  root- 
zones  in  order  to  gain  access  to  the  posterior  grey  horns,  and  these  are 
called  the  inner  radicular  fasciculus  (Charcot).  The  outer  radicular 
fasciculus  passes  along  the  outer  margin  of  the  posterior  horn,  and  between 
it  and  the  pyramidal  tract  of  the  same  side.  It  is  therefore  probable  that 
the  inner  and  outer  radicular  fasciculi  contain  the  earlier-formed  afferent 
fibres,  and  that  consequently  they  preside  over  the  earlier-formed  and 
most  fundamental  functions. 

§  362.  Development  of  the  Central  Orey  Column. 

The  central  grey  column  appears  to  grow  mainly  round  the  central 
artery  as  a  centre.  The  portion  which  immediately  surrounds  the  central 
canal  consists  almost  entirely  of  neuroglia ;  but  the  anterior  and  lateral 
portions  contain,  in  addition,  nerve-fibrils  and  scattered  ganglion  cells, 
the  latter  being  much  smaller  and  not  so  distinctly  caudate  as  those  of 
the  anterior  horns.  This  portion  of  the  grey  substance  contains  a  rela- 
tively large  number  of  Deiter's  cells,  and  the  neuroglia  is  much  more 
spongy  than  in  the  anterior  and  posterior  horns.  The  posterior  and  inner 
part  of  the  central  column  contains  a  group  of  large  caudate  cells— the 
vesicular  column  of  Clarke.  This  group  lies  close  to  the  internal  border 
of  the  posterior  horn,  near  the  posterior  commissure.  It  consists  of  neuroglia 
nerve-fibres  and  ganglion  cells,  the  latter  of  which  are  bipolar,  or  at  least 
not  so  distinctly  caudate  as  those  of  the  anterior  horn.  The  neuroglia  in 
which  the  cells  are  embedded  is  more  dense  and  compact  than  that  of  the 
remaining  portion  of  the  central  column,  being  in  this  respect  similar  to 
the  neuroglia  surrounding  the  cells  of  the  groups  of  the  anterior  horns. 

With  the  exception  of  the  vesicular  column  of  Clarke,  the  central 
column  appears  to  be  the  embryonic  portion  of  the  grey  substance,  the 
portion  adjoining  the  central  canal  being  the  last  formed,  and  consisting 
of  scarcely  anything  but  neuroglia.     As  a  new  layer  of  tissue  grows 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.  81 

around  the  canal  the  central  opening  becomes  smaller  and  smaller,  and 
the  earlier-formed  layers  are  displaced  away  from  the  centre.  The 
later-formed  parts  of  the  anterior  and  posterior  horns  grow  at  the  expense 
of  the  central  column.  But  the  portion  subtracted  from  the  central 
column  by  each  increment  superadded  to  the  anterior  and  posterior  horns 
is  replaced  by  the  growth  of  a  new  layer  of  tissue  around  the  central  canal. 
The  cells  of  the  central  column  do  not  develop  until  a  late  period  of 
embryonic  life,  and  they  may  therefore  be  regarded  as  cells  superadded,  in 
the  course  of  evolution,  to  those  of  the  anterior  and  posterior  horns,  and 
of  the  vesicular  column  of  Clarke,  and  rendered  necessary  by  newly- 
acquired  complications  of  movement.  The  group  of  cells  which  I  have 
described  as  the  median  group  of  the  anterior  horn  may,  indeed,  be  regarded 
as  an  anterior  outgrowth  of  the  central  column,  its  relatively  large  size  in 
the  cervical  region  being  rendered  necessary  by  the  complicated  move- 
ments of  the  hand.  In  addition  to  the  ganglion  cells  and  fibres  belonging 
to  the  central  column  itself,  it  transmits  a  large  number  of  intercom- 
municating fibres. 


§  363.  Longitudinal  Distribution  of  the  Groups  of  Ganglion 

Cells. 

The  remarks  which  have  hitherto  been  made  refer  particularly 
to  the  development  of  the  lumbar  and  cervical  enlargements  of 
the  cord ;  but  a  few  words  must  now  be  said  with  respect  to  the 
distribution  of  the  various  groups  of  ganglion  cells  in  the  other 
portions  of  the  cord.  The  grey  substance  of  the  dorsal  region 
is  represented  in  Fig.  121,  where  it  will  be  seen  that  the  most 
anterior  portion  of  the  anterior  horn  is  occupied  by  three  small 
groups  of  large  ganglion  cells.  These  groups  cannot  be  so  dis- 
tinctly distinguished  in  every  section  as  they  were  in  the  one  from 
which  this  drawing  was  taken;  but  indications  of  such  a  division 
may  be  found  in  most  sections.  These  groups  appear  to  corre- 
spond to  the  internal,  antero-lateral,  and  central  groups  in  the 
cervical  and  lumbar  regions  ;  while  the  median  group  of  small 
cells,  which  is  so  conspicuous  in  the  cervical,  is  wholly  unrepre- 
sented in  the  dorsal  region.  A  very  remarkable  feature  of  the 
grey  substance  of  the  dorsal  region  is  a  comparatively  wide 
area  which  lies  between  the  aotero-lateral  and  postero-lateral 
groups,  and  which  I  have  already  named  the  medio-lateral 
area  {Fig.  121,  ml) ;  it  is  filled  with  small  ganglion  cells,  which 
have  only  developed  processes  towards  the  ninth  month  of 
foetal  life. 


32 


ANATOMICAL  AND   PHYSIOLOGICAL   INTKODUCTION. 


On  passing  now  to  the  upper  cervical  region  of  the  cord,  it 
will  be  observed  that  a  transposition  of  the  ganglion  groups 
takes  place  somewhat  similar  to  that  which  occurs  in  the  dorsal 
region.  Above  the  level  of  the  fifth  cervical  vertebra  the  area 
of  the  median  group  of  small  cells  rapidly  diminishes  in  size, 
so  that  the  antero-lateral  approximates  the  internal  group, 
and  the  small  anterior,  and  probably  also  the  central  groups  dis- 
appear. An  area  of  small  cells  is,  however,  interposed  between 
the  antero-lateral  and  postero-lateral  groups,  which  begins  to 
show  itself  as  low  down  as  the  sixth  cervical  nerve,  and  gradually 
increases  in  size  to  the  upper  end  of  the  cord.  There  the 
median  group  disappears  entirely,  so  that  the  internal  and 
antero-lateral  groups  are  only  separated  by  a  small  vessel, 
while  a  considerable  area  of  small  cells  lies  between  the 
antero-lateral  and  postero-lateral  groups  {Fig.  120  m?).     The 


Fig.  120. 


Fig.  121. 


Tigs.  120  and  121  (Young).  Sections  of  the  AdaU  Human  Spinal  Cord,  from 
the  upper  cervical  and  dorsal  regions  respectively.— A,  anterior,  and  P, 
posterior  horns  ;  aa,  anterior  roots  ;  cc,  central  canal ;  ml,  the  medio-lateral 
area.  The  other  letters  indicate  the  same  as  the  corresponding  ones  in 
Figs.  113  and  114.  The  size  of  the  sections  from  which  the  drawing  was 
taken  is  indicated  above  each.  In  Fig.  121,  w  represents  the  vesicular 
column  of  Clarke. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTKODUCTION.  33 

distribution  of  the  different  groups  in  the  upper  cervical  region 
is,  indeed,  very  similar  to  that  which  occurs  in  the  dorsal  region. 
It  will,  however,  be  seen,  on  comparing  Figs.  120  and  121,  that 
the  central  group  is  unrepresented  in  the  upper  cervical,  while  it 
is  represented  in  the  dorsal  region,  but  this  difference  is  unim- 
portant since  I  am  not  sure  that  the  group  is  always  absent  in 
the  upper  cervical,  or  always  present  in  the  dorsal  region. 
One  important  difference,  however,  exists  between  the  dorsal 
and  upper  cervical  regions  of  the  cord,  and  that  is  the  presence 
of  the  vesicular  column  of  Clarke  in  the  former  and  its  absence 
in  the  latter.  The  vesicular  column  of  Clarke  begins  at  the 
upper  end  of  the  lumbar  enlargement,  where  it  consists  of  a 
group  of  large  bipolar  cells  ;  it  is  continued  upwards  throughout 
the  whole  of  the  dorsal  region,  although  its  cells  are  consider- 
ably smaller  here  than  in  the  upper  lumbar  region,  and  it  ter- 
minates in  the  lower  part  of  the  cervical  enlargement. 

§  364.  TJie  Grey  Substance  of  the  Medulla  Oblongata,  Pons, 
and  Crura  Cerebri. 
In  the  upper  segment  of  the  spinal  cord  both  the  grey  and 
white  substances  undergo  extensive  rearrangement.  One  im- 
portant alteration  of  the  white  substance  is  that  the  column 
of  GoU  increases  in  size  by  the  addition  of  grey  matter — the 
clavate  nucleus — in  its  interior  {Fig.  122,  G,  en),  and  at  a  little 
higher  level  the  posterior  root-zone  also  increases  in  size  by  the 
formation  of  the  triangular  nucleus  in  its  substance  {Fig.  122, 
pr,  tn).  The  increased  size  of  the  posterior  columns  displaces  the 
gelatinous  substance  of  the  posterior  grey  horns  (Fig.  122,  sg), 
so  that  they  extend  in  a  lateral  direction  instead  of  posteriorly 
as  in  the  cord.  Another  rearrangement  of  the  white  substance 
is  produced  by  the  crossing  of  the  lateral  columns,  so  as  to  form 
the  anterior  pyramids  of  the  medulla  {Fig.  122,  x,  P).  These 
fibres  by  their  crossing  cut  off  the  anterior  grey  horns  from  the 
rest  of  the  grey  substance,  while  they  thrust  the  commissures, 
the  central  grey  column,  and  the  central  canal  further  towards 
the  posterior  surface  of  the  medulla.  The  principal  alterations 
of  the  grey  substance,  therefore,  consist  in  the  lateral  displace- 
ment of  the  posterior  horns,  the  slight  posterior  displacement  of 
the  central  canal,  central  grey  column,  and  commissures,  and  the 
D 


34 


ANATOMICAL  AND  PHYSIOLOGICAL  INTEODUCTION. 


detachment  of  the  anterior  horns  from  the  central  grey  column. 
A  careful  examination,  however,  shows  that  one  or  two  other 
minor  but  exceedingly  important  alterations  have  taken  place. 
The  triangular  nucleus  and,  at  a  little  higher  level,  the  clavate 
nucleus   {Fig.  122,  tn,  en)  give  off  arcuate  fibres,  which  are 


Fig.  122  ( Young).    Section  of  the  Lower  End  of  the  Medulla  Oblongata  on  a  level 

with  the  crossing  of  the  fibres  of  the  lateral  column. 
A,  Anterior  grey  horns,  showing  that  the  grey  matter  has  become  mixed  up  with 
the  white  substance  of  the  anterior  root-zone,  and  with  arcuate  fibres. 
i  X  al.  Internal  group  and  a  portion  of  the  antero-lateral  group. 
ale,  Anterior  nucleus  of  the  lateral  column,  being  a  portion  detached  from  the 

antero-lateral  group. 
pic,  Posterior  nucleus  of  the  lateral  column,  being  a  portion  detached  from  the 
postero-lateral  group. 
sg,  Substantia  gelatinosa  displaced  laterally. 
at.  Ascending  root  of  the  trigeminus. 
/,  Fasciculus  rotundus. 
vc,  Vesicular  column  of  Clarke  ? 
P,  Pyramidal  tract, 

X,  Crossing  of  the  fibres. 

ar.  Internal  portion  of  the  anterior  root-zone. 
ar'.  External  portion  of  the  anterior  root-zone. 
XII,  Hypoglossal  nerve. 

XI,  Spinal  accessory  nerve. 

Gr,  The  column  of  GoU — the  slender  fasciculus. 

en.  The  clavate  nucleus. 
pr,  The  posterior  root-zone— the  cuneate  fasciculus. 

tn.  The  triangular  nucleus.  cc.  The  central  canal. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


35 


directed  forwards  and  upwards  in  a  semicircular  manner  to 
reach  the  olivary  body  of  the  same  side.  These  fibres  pass 
through  the  posterior  horns  and  thrust  them  still  further  in  a 
lateral  direction,  and,  indeed,  almost  entirely  separate  the 
greater  portion  of  each  horn  with  its  substantia  gelatinosa  from 
the  grey  substance  which  surrounds  the  central  canal.  The 
arcuate  fibres  interlace  with  the  fibres  of  the  lateral  columns 
as  the  latter  bend  forwards  to  cross,  and  also  detach  a  portion 
of  the  antero-lateral  and  postero-lateral  groups  of  cells,  so  that 
a  portion  of  these  groups  now  extends  into  the  white  substance 
of  the  anterior  root-zones  {Fig.  122,  ale,  pic). 

The  continuation  of  the  anterior  root-zones  {Fig.  122,  ar 
and  ar')  of  the  cord  through  the  medulla  oblongata  is  broken 
up  into  a  reticulated  formation — i\iQ  formatio  reiicularis — first 


Fig.  123. 


Fig.  12.3  (From  Henle's  Anatomie).    Formatio  Reticularis  of  the  Medulla  Oblongata 
showing  the  ganglion  cells  distributed  through  it. 


36         ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


Fig.  124, 


Fig.  124  (Young).     Section  of  the  Medulla  Oblongata  on  a  level  with  the  Glosso- 

X>haryngeal  Nerve. 
P,  Pyramid. 

X),  Accessory  portion  of  the  pyramid. 
Xii,  Hypoglossal  nerve. 

Hj  Nucleus  of  hyiDoglossal.     The  internal,  antero-lateral,  and  postero-lateral 
groups. 

a,  Anterior  group  of  cells. 
IS,  Glosso-pharyngeal  nerve. 

ngp,  Nucleus  of  glosso-pharyngeal. 

VIII,  Lower  part  of  the  posterior  median  acoustic  nucleus 

if.  Internal  accessory  facial  nuclei. 

ef.  External  accessory  facial  nuclei. 

ale,  Anterior  nucleus  of  the  lateial  column. 

pic.  Posterior  nucleus  of  the  lateral  column. 
/,  Fasciculus  rotundus. 

ip,  Internal  division  of  the  inferior  peduncle  of  the  cerehelhxm  ■ 
Gr,  Column  of  Goll. 

en,  Clavate  nucleus. 


ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION.  37 

by  the  arcuate  fibres  of  the  triangular  and  clavate  nuclei,  and 
then  by  the  arcuate  fibres  of  the  inferior  peduncles  of  the  cere- 
bellum, and  the  whole  of  this  tissue  is  thickly  studded  with 
caudate  ganglion  cells,  as  represented  in  Fig.  123.  Whether 
all  these  cells  are  the  representatives  of  those  detached  by  the 
arcuate  fibres  from  the  antero-lateral  and  postero-lateral  groups 
of  the  cord  is  not  known.  The  cells  detached  from  these 
groups,  however,  aggregate  into  two  more  or  less  distinct  groups 
in  the  lateral  part  of  the  formatio  reticularis  of  the  medulla. 
These  groups  may  from  their  position  be  called  the  anterior  and 
posterior  nuclei  of  the  lateral  column  of  the  medulla  {Figs.  122, 
124,  and  125,  ale,  pic);  while  the  terms  antero-lateral  and 
postero-lateral  may  still  be  retained  to  designate  what  I 
believe  to  be  the  upward  continuations  of  the  portions  of  the 
antero-lateral  and  postero-lateral  (Fig.  109,  al,  pi)  groups  of 
the  cord  which  have  retained  their  connection  with  the  grey 
matter  that  may  be  considered  as  representing  the  anterior 
cornua. 

§  365.  Continuation  of  the  Anterior  Grey  Horns  of  the 
Spinal  Cord  through  the  Medulla  Oblongata,  Pons,  and  Crura 
Cerebri. — This  slight  digression  into  the  examination  of  the 
rearrangement  of  the  white  substance,  which  takes  place  in 
passing  from  the  spinal  cord  to  the  medulla  oblongata,  appeared 
necessary  in  order  fully  to  understand  the  redistribution  of 
the  groups  of  ganglion  cells  occurring  in  the  medulla.  At 
the  lower  end  of  the  medulla  portions  of  the  antero-lateral 
and  postero-lateral  groups  may  be  seen  to  extend  laterally 
into  the  substance  of  the  anterior  root-zone,  or  into  the  lateral 
column  of  the   medulla   oblongata  as  it  may  now  be  called. 


jjr,  Posterior  root-zone. 

tn.  Triangular  nucleus. 
dc,  The  direct  cerebellar  tract  lying  on  the  surface  of  the  posterior  root-zone,  and 

the  ascending  root  of  the  trigeminus. 
at,  Ascending  root  of  the  trigeminus. 

sg,  Substantia  gelatinosa. 
L,  Posterior  longitudinal  fasciculus. 
ar,  The  portion  of  the  formatio  reticularis,  which  represents  the  internal  division 

of  the  anterior  root-zone  of  the  spinal  cord. 
ar',  The  portion  of  the  formatio  reticularis,  which  represents  the  external  division 

of  the  anterior  root-zone  of  the  spinal  cord. 
0,  Olivary  body. 

np.  Nucleus  of  the  pyramid. 
po,  Parolivary  body. 


38         ANATOMICAL  AND  PHYSIOLOGICAL   INTKODUCTION. 

From  the  anterior  nucleus  of  the  lateral  column  (Fig.  122,  ale), 
fibres  maybe  observed  proceeding  inwards  and  passing  between 
the  antero-lateral  and  postero-lateral  groups.  Some  of  these 
fibres  cross  over  and  appear  to  be  connected  with  the  spinal 
accessory  nerve  of  the  opposite  side.  Others  wind  round  the 
postero-lateral  group  to  get  to  the  spinal  accessory  nerve  of 
the  same  side.  From  the  posterior  nucleus  of  the  lateral  column 
{Fig.  122,  pic),  fibres  proceed  inwards  to  reach  the  grey  sub- 
stance, and  wind  backwards  along  the  boundary  line  between  the 
white  and  grey  substance  to  reach  the  spinal  accessory  nerve  of 
the  same  side.  The  nuclei  of  the  lateral  column,  therefore, 
appear  to  give  origin  to  some  at  least  of  the  fibres  of  the 
spinal  accessory  nerve ;  and  we  have  only  to  suppose  that  the 
same  arrangement  is  carried  out  as  we  ascend  the  medulla  and 
pons  in  order  to  understand  the  origin  of  the  motor  fibres  of 
the  pneumogastric  and  glosso-pharyngeal  nerves,  those  of  a 
large  part  of  the  facial  nerve,  and  of  the  motor  root  of  the  fifth. 
The  arrangement  of  the  fibres  from  the  nuclei  of  the  lateral 
column  which  pass  out  along  with  the  glosso-pharyngeal  nerve  is 
represented  in  Fig.  124.  The  fibres  from  the  anterior  nucleus 
{Fig.  124*,  ale)  proceed  backwards  and  inwards,  and  pass  between 
what  will  be  afterwards  described  as  the  antero-lateral  and 
postero-lateral  groups.  I  have  not  been  able  to  assure  myself 
that  any  of  these  fibres  cross  over  to  the  opposite  side,  although 
this  is  probable ;  but  some  of  them  may  be  distinctly  observed 
to  wind  round  the  postero-lateral  nucleus  to  proceed  in  the 
direction  of  the  glosso-pharyngeal  nerve.  The  fibres  from  the 
posterior  nucleus  {Fig.  124,  pZc)  proceed  backwards  and  inwards, 
and  on  reaching  the  grey  substance  bend  abruptly  outwards 
along  the  edge  of  the  white  substance  to  reach  the  nerve.  A 
similar  arrangement  may  be  observed,  at  a  lower  level,  with 
respect  to  the  pneumogastric  and  spinal  accessory  nerves.  At 
a  higher  elevation  the  fibres  from  the  nuclei  of  the  lateral 
column  proceed  backwards  and  inwards,  the  majority  of  them 
(genu  nervi  facialis)  wind  round  the  nucleus  of  the  sixth  nerve, 
and  proceed  outwards  to  join  the  facial  nerve.  The  fibres  from 
the  posterior  nucleus  of  the  lateral  column  {Fig.  126,  pic) 
appear  to  me  to  pass  backwards  and  to  the  outside  of  the  nucleus 
of  the  sixth  nerve  to  join  the  facial.     The  anterior  nucleus  of 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 


39 


the  lateral  column  appears  to  terminate  on  a  level  with  the 
origin  of  the  facial  nerve.  Fibres,  however,  seem  to  pass  upwards 
and  backwards  from  this  nucleus  to  join  the  motor  root  of  the 
fifth  nerve.  In  Fig.  127  the  anterior  nucleus  of  the  lateral 
column  of  the  medulla  is  not  represented,  but  the  fibres  trans- 
versely cut  at  (r)  shows  that  these  have  joined  the  others  from 

Fig.  125. 


Fig.  12-5  (Modified  from  Flechsig).    Section  of  the  Medulla  Oblongata  on  a  level 

tvith  the  superficial  origin  of  the  Acoustic  Nerve. 
E,  VIII,  Root  of  the  acoustic  nerve. 

VIII,  Posterior  median  acoustic  nucleus. 
VII i",  Posterior  lateral  acoustic  nucleus. 
H,  Niicleus  of  the  hypoglossal  nerve. 
ip,  Internal  division  of  the  inferior  peduncle  of  the  cerebellum. 
ep.  External  division  of  the  inferior  peduncle  of  the  cerebellum. 
frs,  Formatio-reticularis. 

a,  Arcif orm  fibres.    The  remaining  letters  indicate  the  same  as  the  corresponding 
letters  in  Fig.  124. 


40 


ANATOMICAL  AND  PHYSIOLOGICAL  INTEODUCTION. 


a  differeDt  level,  and  I  "believe  that  these  fibres  have  ascended 
from  the  anterior  nucleus  of  the  lateral  column.  The  motor 
nucleus  of  the  fifth  {Fig.  127,  v)  appears  to  be  the  continuation 
upwards  of  the  posterior  nucleus  of  the  lateral  column.  The 
nucleus  now  lies  close  to  the  sensory  fibres  of  the  nerve,  and  its 
fibres,  instead  of  winding  backwards  at  first,  as  they  do  at  a 
lower  level,  appear  to  pass  outwards  at  once  by  the  side  of  the 
sensory  fibres. 

The  groups  of  cells  of  the  anterior  horns  may  be  traced 
upwards  more  or  less  distinctly  to  the  nucleus  of  origin  of 
the  hypoglossal  nerve.  The  hypoglossal  nerve  begins  on  a 
level  with  the  upper  limit  of  the  crossing  of  the  fibres  of  the 
pyramidal  tract.     The  crossing  of  the  fibres  had  detached  the 


Fig.  126. 


\ 


BVti 


r 


yf  '\7i\\ 


Fig.  126  (Modified  from  Erb).  Transverse  Section  of  the  Pons  on  a  level  with  the 
Abducens  and  Facial  Boots,  from  a  nine  months  embryo. — The  right  half  repre- 
sents a  section  made  a  little  lower  than  the  left.  P,  Pyramidal  tract ;  p, 
accessory  portion  of  the  pyramidal  tract;  Tr  and  Tr',  transverse  fibresof  the 
pons ;  so,  superior  olivary  body ;  ale  and  pic,  anterior  and  posterior  nuclei  of  the 
lateral  column  respectively,  representing  the  nucleus  of  the  facial  nerve  ;  EVll, 
root  of  the  facial  nerve ;  vi',  nucleus  of  the  sixth  nerve ;  KVi,  root  of  the  sixth 
nerve ;  at,  ascending  root  of  the  trigeminus.  B,  The  internal  division  of  the 
peduncle  of  the  cerebellum  as  it  passes  from  the  cerebellum ;  L,  posterior  longi- 
tudinal fasciculus ;  ar  and  ar',  the  upward  continuation  of  the  internal  and 
external  divisions  of  the  anterior  root-zone  of  the  spinal  cord ;  t,  fasciculus  teres. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


41 


anterior  horns  from  the  grey  substance  surrounding  the  central 
canal;  but  when  the  crossing  is  completed,  these  two  portions 
again  become  united.  The  olivary  body  is,  however,  inter- 
calated, the  whole  of  the  grey  matter  is  thrust  further  and 
further  back  until  the  posterior  commissure  disappears,  and  the 
central  canal  opens  at  the  calamus  scriptorius  on  the  floor  of 
the  fourth  ventricle.  The  nucleus  of  the  hypoglossal  nerve  is 
often  described  as  if  its  cells  constituted  one  group.  These 
cells  are,  however,  distinctly  arranged  into  several  groups  which 
correspond  so  closely  with  the  arrangement  of  the  groups  in  the 
anterior  horns  of  the  cord  that  I  have  no  hesitation  in  regard- 
ing those  of  the  former  as  continuations  of  the  latter.     An 


Fig.  127. 


Fig.  127  (Modified  from  Erb\  Transverse  Section  of  the  Pons  on  a  level  with  the  origin 
of  the  Trigeminus,  from  a  nine  months  human  embryo. — P,  pyramidal  tract ;  p, 
accessory  portion  of  the  pyramidal  tract ;  Tr,  Tr',  transverse  fibres  of  the  pons  ; 
at,  ascending  root  of  the  trigeminus  and  gelatinous  substance  ;  dt,  descending  root 
of  the  trigeminus ;  r,  root-fibres  of  the  trigeminus  cut  transversely ;  v,  motor 
nucleus  of  the  trigeminus  ;  v',  middle  sensory  trigeminal  nucleus  ;  RV,  root  of 
trigeminus ;  C,  roots  of  the  fifth  proceeding  from  the  cerebellum ;  L,  Poste- 
rior longitudinal  fasciculus ;  ar  and  ar',  upward  continuation  of  the  internal 
and  external  portions  respectively  of  the  anterior  root-zone  of  the  spinal  cord. 


42 


ANATOMICAL   AND   PHYSIOLOGICAL  INTRODUCTION. 


internal,  antero-lateral,  and  postero-lateral  {Fig.  109,  i,  al,  pi) 
group  may  be  distinguished,  and  these  appear  to  correspond  to 
the  groups  of  the  same  name  in  the  cord  ;  while  a  large  number 
of  cells  may  be  observed  at  the  roots  of  the  hypoglossal  nerve 
{Fig.  109,  a),  which  may  be  called  the  anterior  group,  and 
which  corresponds  to  the  anterior  group  in  the  cord.  All  that 
has  been  previously  said  with  regard  to  the  development  of 
the  groups  of  cells  in  the  anterior  horns  of  the  cord  applies 
equally  to  those  of  the  hypoglossal  nucleus.  The  central  cells 
of  the  latter  groups  develop  first,  while  the  marginal  cells 
develop  last  and  close  to  the  blood-vessels  which  ramify  between 
the  groups  as  they  do  in  the  cord. 

Fig.  128, 


Tig.  128  (Modified  from  Meynert).  Transverse  Section  of  the  Pons  on  a  level  with  the 
upper  end  of  the  Fourth  Ventricle,  from  a  nine  months  human  embryo.— F,  pyra- 
midal tract ;  p,  accessory  portion  of  the  pyramidal  tract ;  Tr,  Tr',  transverse 
fibres  of  the  pons ;  B,  superior  brachium  of  the  pons  ;  L,  posterior  longitudinal 
fasciculus  ;  ar  and  ai-',  upward  continuation  of  the  internal  and  external  portions 
respectively  of  the  anterior  root-zone  of  the  spinal  cord;  v',  middle  sensory 
trigeminal  nucleus ;  dt,  descending  root  of  the  trigeminus  ;  iv,  nucleus  of  the 
fourth  nerve  ;  cc,  aqueduct  of  Sylvius. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTKODUCTION. 


43 


It  is  not  easy  to  trace  the  continuation  of  the  groups  of  cells 
of  the  anterior  horns  of  the  cord  beyond  the  nucleus  of  the  hypo- 
glossal nerve,  inasmuch  as  the  groups  become  separated  longitu- 
dinally by  the  transverse  fibres  of  the  pons.  It  is,  however,  pro- 
bable that  the  nucleus  of  the  sixth  nerve  {Fig.  126,  vi')  represents 
the  postero-lateral  group,  and  the  bending  of  the  fibres  of  the 
facial  nerve  round  the  nucleus  corresponds  to  the  similar  bend- 
ing of  the  fibres  which  issue  from  the  anterior  nucleus  of  the 
lateral  column  in   the  lower  part  of  the  medulla  round  the 

Fig.  129. 


Fig.  129  (Modified  from  Krause).  Transverse  Section  of  the  Cms  Cerebri  on  a  level 
with  the  anterior  pair  of  Corpora  Quadrigemina,  from  a  nine  months  embryo. — 
cc,  crusta ;  P,  pyramidal  tract ;  p,  accessory  portion  of  the  pyramidal  tract ; 
LN,  locus  niger ;  RN,  red  nucleus  of  the  tegmentum  ;  L,  posterior  longitudinal 
fasciculus ;  ar  and  ar',  upward  continuation  of  the  internal  and  external  portions 
respectively  of  the  anterior  root-zone  of  the  spinal  cord  ;  ill,  third  nerve ; 
III',  nucleus  of  the  third  nerve  ;  iv,  fourth  nerve ;  iv',  nucleus  of  the  fourth 
nerve  ;  _iv",  crossing  of  the  fibres  of  the  fourth  nerves  to  opposite  sides  ;  dt, 
descending  root  of  the  trigeminus  ;  cc,  aqueduct  of  Sylvius  ;  x,  crossing  of  the 
fibres  of  the  superior  peduncles  of  the  cerebellum  ;  pf,  fasciculus  of  medullated 
fibres  proceeding  to  the  anterior  pair  of  corpora  quadrigemina. 


44?  ANATOMICAL   AND   PHYSIOLOGICAL  INTRODUCTION. 

postero-lateral  group  to  join  the  spinal  accessory  nerve.  The 
postero-lateral  group  cannot  be  traced  beyond  the  nucleus  of 
the  sixth  nerve,  and  probably  ceases  there.  The  internal,  an- 
terior, and  antero-lateral  groups  are  dislocated  upwards,  as  a 
result  probably  of  the  longitudinal  extension  of  the  central  grey 
tube,  which  is  rendered  necessary  in  order  to  provide  accommo- 
dation for  the  large  mass  of  the  transverse  fibres  of  the  pons. 
These  groups  reappear  in  front  of  the  aqueduct  of  Sylvius,  and 
form  the  nuclei  of  the  third  and  fourth  nerves  (Fig.  129,  ill',  iv'). 
The  fourth  nerve  is  in  my  opinion  merely  a  portion  detached 
from  the  third  by  the  decussating  fibres  of  the  superior 
peduncles  of  the  cerebellum,  and  thus  compelled  to  seek  its 
destination  by  an  independent  route.  The  fourth  nerve,  there- 
fore, appears  to  belong  to  the  system  of  anterior  motor  nerves 
represented  by  the  hypoglossal,  sixth,  and  third  nerves,  and 
not  to  the  "mixed  lateral  system"  represented  by  the  spinal 
accessory,  vagus,  glosso-pharyngeal,  and  fifth  nerves.  Although 
the  facial  is  a  purely  motor  nerve,  it  appears  to  belong  at 
least  in  part  to  that  lateral  system.  That  the  nucleus  of 
the  sixth  on  the  one  hand  and  that  of  the  third  and  fourth 
on  the  other  really  belong  to  the  same  nucleus,  and  are 
only  separated  from  one  another  by  some  structure  being 
intercalated  in  the  course  of  evolution,  is  rendered  probable  by 
the  fact  that  the  nucleus  of  the  sixth  is  connected  with  a  portion 
of  the  nucleus  of  the  third  of  the  opposite  side  by  a  distinct 
bundle  of  fibres  (Duval).  The  fact  that  these  nerves  are  so 
closely  related  in  their  functions  affords  further  corroborative 
evidence  in  favour  of  this  opinion. 

§  366.  Continuation  of  the  Posterior  Gr^y  Horns  of  the 
Spinal  Cord  through  the  Medulla  Oblongata,  Pons,  and  Crura 
Cerebri. — We  have  already  seen  that  the  substantia  gelatinosa 
of  the  posterior  horns  was  not  only  thrust  out  laterally,  but  also 
almost  detached  from  the  rest  of  the  grey  substance  by  the 
arcuate  fibres,  and  we  must  now  observe  that  it  maintains  this 
lateral  and  superficial  position  as  high  as  the  level  of  the  point 
of  emergence  of  the  fifth  nerve  {Figsi.  124  to  127,  at).  It 
may,  indeed,  be  said  that  this  structure  is  continued  upwards 
to  the  level  of  the  opening  of  the  aqueduct  of  Sylvius  into  the 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.  45 

third  ventricle,  since  the  descending  root  of  the  fifth  nerve 
appears  to  be  a  somewhat  similar  structure  to  the  ascending 
root  and  gelatinous  substance  {Figs.  127  to  129,  dt).  The 
white  substance  of  the  ascending  root  appears  to  be  the  analogue 
of  the  posterior  root-zones  of  the  cord — a  mere  continuation 
upwards  of  these  zones,  after  what  belongs  to  the  spinal  portion 
of  the  central  grey  tube  has  terminated  in  the  clavate  nucleus. 

§  367.  Continuation  of  the  Central  Column  and  the  Vesicular 
Column  of  Clarke  through  the  Medulla  Oblongata. 
In  the  lower  end  of  the  medulla  the  central  column  becomes 
separated  from  the  anterior  horn  by  the  decussating  pyramidal 
fibres,  and  almost  separated  from  the  posterior  grey  horns  by 
the  lateral  displacement  of  the  latter.  A  bundle  of  transverse 
fibres  still  connect  the  central  column  and  the  posterior  horns, 
and  these  separate  so  as  to  leave  an  interspace  in  which  longi- 
tudinal fibres  may  be  observed  to  ascend  towards  the  medulla. 
These  form  a  round  bundle  (Figs.  1 22  and  124,  f),  which  reaches 
as  far  as  the  upper  end  of  the  glosso-pharyngeal  nucleus,  and  has 
been  called  the  "  ascending  root  of  the  lateral  mixed  system  " 
by  Meynert,  and  the  "  respiratory  fascicle"  by  Krause.  In  the 
dorsal  region  of  the  spinal  cord  the  middle  portion  of  the  grey 
substance  is  represented  by  two  columns  on  each  side  of  the 
central  canal — the  vesicular  column  of  Clarke,  and  the  central 
column — but  the  column  of  Clarke  is  unrepresented  in  the  lum- 
bar and  cervical  regions  of  the  cord.  It  appears  to  me,  however, 
that  the  vesicular  column  of  Clarke  again  becomes  represented 
m  the  lower  end  of  the  medulla.  A  group  of  cells  may  be 
observed  near  the  posterior  and  internal  margin  of  the  central 
column  in  the  lower  end  of  the  medulla  {Fig.  122,  vc),  corre- 
sponding to  the  position  occupied  by  the  vesicular  column  of 
Clarke  in  the  dorsal  region ;  and  the  cells  of  both  groups  mani- 
fest a  tendency  to  be  bipolar  instead  of  multipolar,  like  those  of 
the  anterior  horns.  Assuming,  therefore,  that  the  group  of  cells 
in  the  middle  portion  of  the  grey  matter  in  the  lower  end  of  the 
medulla  is  the  upward  continuation  of  the  vesicular  column  of 
Clarke,  and  that  the  remaining  portion  represents  the  central 
column  in  the  cord,  we  shall  have  no  difficulty  in  tracing  the 
disposition  of  these  portions  of  grey  substance  in  the  medulla. 


46 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 


Immediately  above  the  crossing  of  the  pyramidal  fibres,  where 
the  anterior  horns  are  pressed  backwards  towards  the  central 
canal,  the  central  column  lies  posterior  to  the  groups  of  cells 
representing  the  anterior  horns,  and  close  to  the  central  canal, 
while  the  representative  of  the  vesicular  column  of  Clarke  lies 
external  to  the  central  column,  and  posterior  to  the  groups 
representing  the  anterior  grey  horns  {Fig.  130,  xi).  The 
nucleus  which  represents  the  vesicular  column  of  Clarke  con- 
tains pigmented  bipolar  cells,  and  constitutes  the  posterior 
nucleus  of  the  spinal  accessory  nerve  {Fig.  130,  xi').  And 
when  the  central  canal  has  opened  into  the  floor  of  the  fourth 

Fm.  130. 


Fia.  130  (Young).    Section  of  the  Medulla  Oblongata,  a  little  below  the  point  of  the 

Calamus  Scriptorius,  showing  the  groups  of  cells  of  the  grey  substance. 
Rxi,  Fibres  of  origin  of  the  eleventh  or  spinal  accessory  nerve. 

XI,  Posterior  nucleus  of  the  eleventh  nerve. 

xi',  Accessory  nucleus  of  the  eleventh  nerve. 
Rxil,  Fibres  of  origin  of  the  twelfth  or  hypoglossal  nerve. 

a,  i,  al,  pi,  Anterior,  internal,  antero-lateral,  and  postero-lateral  groups  of 
cells  respectively. 

ah,  Accessory  hypoglossal  nucleus. 

if.    Internal  accessory  facial  nuclei. 

ef  External  accessory  facial  nucleus. 
C,  Central  canal. 
/,  Fasciculus  rotundus. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.  47 

ventricle,  the  representative  of  tlae  vesicular  column  of  Clarke 
is  thrust  backwards,  and  laterally  so  as  to  form  the  principal 
part  of  the  nuclei  of  origin  of  the  spinal  accessory,  vagus,  and 
glosso-pharyngeal  nerves,  while  the  central  column  winds  round 
the  groups  representing  the  anterior  horns  {Fig.  124,  H),  so  as 
to  lie  internal,  posterior,  and  external  to  them.  The  posterior 
portion  of  the  central  column  is  elevated  into  a  ridge  (funiculus 
teres)  close  to  the  median  fissure  in  the  inferior  part  of  the  floor 
of  the  fourth  ventricle  {Fig.  124,  if).  The  central  column  is 
continued  upwards,  as  a  thin  film  of  grey  substance,  on  the 
floor  of  the  fourth  ventricle,  and  lying  behind  the  fibres  of 
origin  of  the  facial  {Fig.  126,  t)  and  the  fifth  {Fig.  127,  r); 
while  in  the  upper  end  of  the  pons  and  crura  it  is  represented 
by  the  grey  matter  which  immediately  surrounds  the  aqueduct 
of  Sylvius  {Figs.  128  and  129,  cc). 

The  characteristics  of  the  central  column  are,  as  we  have 
already  seen,  that  its  texture  is  spongy,  rendering  it  transparent 
on  section,  and  that  its  cells  are  comparatively  late  in  their 
development.  We  saw  reason,  indeed,  to  regard  the  central 
column  as  being  the  embryonic  part  of  the  central  grey  tube, 
and  that  the  portions  of  it  which  are  first  developed  are  thrust 
outwards  as  new  layers  grow  about  the  central  canal.  If  this 
be  true,  we  may  expect  to  find  that  any  additional  nuclei  which 
may  form  in  the  medulla  oblongata  in  the  course  of  development 
will  grow  in  the  representative  of  the  central  column.  This 
expectation  is  realised.  Whether  the  spongy  portion  of  grey 
substance,  which  lies  internal,  posterior,  and  external  to  the 
hypoglossal  nucleus,  be  or  be  not  the  continuation  upwards 
of  the  central  column,  several  groups  of  cells  may  be  observed 
in  it  which  do  not  become  developed  until  subsequently  to  the 
ninth  month  of  embryonic  life,  and  which  do  not  appear  to  be 
represented  in  the  spinal  cord ;  they  may,  therefore,  be  called 
the  accessory  nuclei  of  the  medulla  oblongata.  These  nuclei 
must  be  carefully  distinguished  from  the  nuclei  of  origin  of  the 
spinal  accessory  nerve. 

§  368.  Accessory  Nuclei  of  the  Medulla  Oblongata. 
(1)  Accessory  Nuclei  of  the  Facial  Nerve. — The  first  of  these 
which  I  shall  mention  is  what  has  been  described  by  Dr.  Lock- 


48         ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION. 

hart  Clarke  as  the  inferior  facial  nucleus.  This  nucleus  consists 
really  of  several  small  nuclei.  Two  of  these,  which  may  be 
called  the  internal  accessory  facial  nuclei  {Fig.  130,  if),  appear 
as  two  small  round  nuclei  close  to  the  inner  side  of  the  hypo- 
glossal nucleus  and  the  central  canal ;  and  when  the  canal  opens 
on  to  the  floor  of  the  fourth  ventricle,  they  are  situated  imme- 
diately beneath  the  ependyma  of  the  ventricle,  and  close  to  the 
middle  line  {Fig.  124,  if).  Fibres  from  these  nuclei  ascend  in 
the  funiculus  teres  and  enter  the  fasciculus  teres  {Fig.  126,  t), 
through  which  they  join  the  other  fibres  of  the  facial  nerve. 

Another  somewhat  larger  group  of  small  cells  is  situated 
at  first  posterior  {Fig.  126,  ef)  and  then  external  {Fig.  124, 
ef)  to  the  nucleus  of  the  hypoglossal.  The  fibres  which 
issue  from  it  also  join,  I  believe,  the  fasciculus  teres,  and  the 
group  may,  therefore,  be  called  the  external  accessory  facial 
nucleus  {Fig.  109,  ef).  The  cells  of  these  nuclei  are  small,  and 
destitute  of  processes  in  a  nine  months  embryo. 

(2)  Accessory  Nuclei  of  the  Eleventh  Nerve. — Two  groups  of 
small  cells,  which  develop  at  a  comparatively  late  period,  may 
be  observed  lying  behind  the  posterior  nucleus  of  the  eleventh 
nerve  {Fig.  130,  xi').  Meynert  thinks  that  the  cells  of  these 
groups  are  connected  with  commissural  fibres  which  run  behind 
the  central  canal,  before  it  opens  into  the  fourth  ventricle. 

(3)  Accessory  Nucleus  of  the  Hypoglossal  Nerve. — The  next 
most  important  nucleus  of  this  category  is  one  which  I  have 
constantly  observed  in  the  hypoglossal  nucleus  of  one  side  only 
{Fig.  130,  ah).  As  I  have  not  marked  my  sections,  I  am  at 
present  unable  to  say  whether  it  is  found  on  the  right  or  left 
side.  This  nucleus  is  of  a  round  form,  and  appears  as  if  it 
were  surrounded  by  a  layer  of  white  fibres,  arranged  longi- 
tudinally, which  separates  it  from  the  surrounding  tissue.  It 
contains  a  large  number  of  very  small  caudate  cells,  each 
being  not  one-fifth  the  diameter  of  the  cells  of  the  hypo- 
glossal nucleus.  The  nucleus  in  some  sections  lies  between 
the  internal  and  external  convolute  of  the  nucleus  of  the 
hypoglossal;  while  at  other  times  it  is  embedded  in  the  sub- 
stance of  the  internal  convolute,  being  then  situated  near  the 
margin  of  the  group  {Fig.  130).  This  nucleus  is  almost  entirely 
limited  to  one  side,  although  faint  traces  of  it  may  occasionally 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.  49 

be  observed  in  the  opposite  side;  it  is  scarcely  recognisable  on 
either  side  of  the  medulla  at  the  ninth  month  of  embryonic 
life.  The  most  reasonable  supposition  with  regard  to  it  is  that 
it  regulates  the  movements  of  articulation,  and  that  it  is  con- 
nected with  the  third  left  frontal  convolution  of  the  brain. 

§  369.  Special  Nuclei  of  the  Medulla  Oblongata  and  Pons. 

(1)  The  acoustic  nuclei  can  scarcely  be  said  to  be  repre- 
sented by  any  portion  of  the  grey  substance  of  the  cord.  These 
nuclei  are  four  in  number : — 

{a)  The  posterior  median  nucleus  of  the  acousticus 
{Fig.  125,  vili)  comes  in  contact  with  the  nucleus  of  the 
vagus,  but  is  more  superficially  situated  than  that  of  the 
latter,  and  somewhat  to  the  outer  side  of  the  glosso- 
pharyngeal nucleus.  It  occupies  the  whole  space  between 
the  ala  cinerea  and  inferior  peduncle  of  the  cerebellum  up 
to  the  anterior  border  of  the  striae  medullares.  The  posterior 
root  of  the  acoustic  nerve  takes  its  origin  chiefly  from  this 
nucleus,  and  passes  out  partly  in  superficial  fasciculi  (striae 
acousticae)  and  partly  through  the  body  of  the  medulla. 

(6)  The  posterior  lateral  acoustic,  nucleus  {Fig.  125,  viii") 
is  a  grey  nodule  lying  in  the  peduncle  of  the  cerebellum, 
between  the  deep  and  superficial  fibres  of  origin  of  the  acoustic 
nerve. 

(c)  The  anterior  tnedian  acoustic  nucleus  belongs  to  the 
anterior  roots  of  the  acoustic  nerve,  and  is  situated  anterior 
to  the  striae  medullares.  It  occupies  the  external  angle  of  the 
fourth  ventricle,  about  the  middle  of  the  cerebellar  peduncle.- 

{d)  The  anterior  lateral  acoustic  nucleus  appears  like  a 
prolongation  of  the  posterior  lateral  acoustic  nucleus,  and  is 
wedged  in  between  the  middle  peduncle  and  the  flocculus. 
It  gives  origin  to  the  portio  intermedia  Wrisbergii.  Some 
anatomists  believe  that  the  fibres  which  pass  in  the  chorda 
tympani,  and  which  confer  taste  on  the  anterior  two-thirds  of 
the  tongue,  are  derived  from  the  nerve  of  Wrisberg  (Bigelow). 
It  is  also  probable  that  one  of  the  other  nuclei — perhaps  the 
posterior  lateral  acoustic  nucleus — gives  origin  to  the  fibres 
supplied  to  the  labyrinth,  and  is  not  connected  with  the  purely 
acoustic  fibres. 


50         ANATOMICAL   AND   PHYSIOLOGICAL  INTRODUCTION. 

(2)  The  corpora  quadrigemina  and  geniculate  bodies  are  the 
nuclei  of  origin  of  the  second  or  optic  nerve  ;  but  we  are  unable 
to  say,  in  the  present  state  of  our  knowledge,  what  structures 
constitute  the  nuclei  of  origin  of  the  first  or  olfactory  nerve. 

§  370.  Superadded  Grey  Matter  of  the  Medulla  Oblongata 

and  Pons. 

(1)  The  Clavate  Nucleus. — The  columns  of  Goll  contain  in 
the  lower  part  of  the  medulla  a  nucleus  of  grey  matter,  which  is 
from  its  form  called  the  clavate  nucleus  {Figs.  122  and  124,  en). 
It  is  a  longitudinal  pillar  of  grey  substance,  and  produced  the 
enlargement  in  the  fasciculus  gracilis,  known  as  the  clava. 

(2.)  The  triangular  nucleus  {Figs.  122  and  124,  tn)  is  a 
grey  nucleus  enclosed  in  the  cuneate  fasciculus,  the  latter  of 
which  is  the  continuation  upwards  of  the  posterior  root-zones 
of  the  cord.  It  is  a  longish  grey  body  on  the  inner  border  of 
the  cuneiform  column,  and  enlarging  as  it  ascends.  The  clavate 
and  triangular  nuclei  extend  to  the  posterior  end  of  the  postero- 
lateral acoustic  nucleus. 

(3)  The  olivary  body  {Fig.  124,  o)  is  situated  in  the  lateral 
columns  of  the  medulla,  close  to  the  anterior  pyramid.  In  form 
it  is  like  a  bean  or  an  almond,  with  the  hilus  directed  inwards. 
It  contains  a  number  of  small  ganglion  cells,  and  is  in  substance 
very  similar  to  the  corpus  dentatum  of  the  cerebellum. 

(4)  The  parolivary  body  {Fig.  124,  po)  is  a  band  of  grey 
matter  which  bounds  the  internal  half  of  the  posterior  border 
of  the  olivary  body. 

(5)  The  nucleus  of  the  pyramid  {Fig.  124,  np)  (internal 
parolivary  body)  lies  opposite  the  pyramid,  in  front  and  to 
the  inside  of  the  olivary  body. 

(6)  The  superior  olivary  body  {Fig.  126,  so)  is  a  longish, 
grey  column,  situated  in  the  pons  in  front  of  the  facial  nucleus. 

(7)  The  red  nucleus  of  the  tegmentum  {Fig.  129,  RN)  of 
Stilling,  or  superior  olive  of  Luys,  is  situated  in  the  crus  cerebri, 
between  the  crus  and  tegmentum,  and  is  similar  in  structure 
to  the  olivary  body. 

(8)  The  middle  sensory  nucleus  of  the  trigeminus  {Figs.  127 
and  128,  v')  is  also  a  superadded  structure.  This  nucleus  is 
situated  in  the  substance  of  the  afferent  fibres  of  the  trigeminus, 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.         51 

not  far  from  their  entrance  into  the  pons.  In  structure  it 
is  somewhat  similar  to  that  of  the  ganglia  of  the  posterior 
roots,  and  it  may  represent  the  ganglion  of  the  descending 
roots,  while  the  Gasserian  ganglion  represents  that  of  the 
ascending  roots  of  the  nerve. 

§  371.  Development  of  tJie  White  Substance  of  the  Cord. 

The  white  substance  is  formed  on  the  surface  of  the  deeper  grey 
substance.  Soon  after  the  tube  which  forms  the  rudiment  of  the  cord 
has  closed,  it  is  seen  to  be  somewhat  oval  on  section,  with  a  central  canal. 
At  this  period  the  cord  consists  almost  entirely  of  grey  matter  ;  and  by 
the  appearance  of  lateral  slits  each  lateral  half  becomes  imperfectly 
divided  into  two  parts,  the  anterior  and  posterior.  In  the  human  embryo 
a  zone  of  white  substance  appears  towards  the  end  of  the  first  month  on 
the  exterior  of  each  of  these  parts  ;  and  these  may  respectively  be  called 
the  anterior  and  posterior  root-zones  {Fig.  1 3 1 ,  a,  ^).    The  anterior  portions 

Fig.  131. 


Fig.  131  (From  Eolliker).  Transverse  Section  of  tht  Cervical  Part  of  the  Spinal 
Cord  of  a  Human  Embryo  of  six  weeks. — c,  Central  canal ;  e,  e',  Its  epithelial 
lining  ;  g.  Grey  substance  ;  ar.  Anterior  roots ;  pr.  Posterior  roots ;  a.  Anterior 
root-scones ;  2^,  Posterior  root-zones. 

of  what  are  afterwards  the  lateral  columns  of  the  cord  develop  as  parts  of 
the  anterior  root-zones,  but  the  posterior  portions  do  not  begin  to  develop 
until  about  two  weeks  later.  The  portions  last  developed  appear  to  belong 
to  the  posterior  root-zones,  and  join  them  in  the  medulla  to  form  the 
restiform  bodies ;  and  Flechsig  thinks  that  they  pass  directly  to  the  cortex 
of  the  cerebellum,  hence  they  may  be  called  the  direct  cerebellar  fibres  of 
the  lateral  columns. 

At  the  end  of  the  eighth  week,  then,  the  grey  substance  of  the  cord  in 
the  human  embryo  is  covered  anteriorly,  posteriorly,  and  laterally  by  a 


52 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


layer  of  white  substance  ;  but  at  tbis  period  very  remarkable  cbanges  take 
place.  Two  bundles  of  longitudinal  fibres,  one  for  each  side,  are  inter- 
calated between  the  direct  cerebellar  fibres  of  the  lateral  columns  and  the 
posterior  horns  of  grey  matter.  These  bundles  on  being  traced  upwards 
are  found  to  pass  forwards  at  the  lower  end  of  the  medulla,  and  after 
decussating  with  one  another  they  push  aside  the  anterior  columns,  and 
form  the  inner  and  larger  portion  of  the  anterior  pyramids  of  the  medulla; 
hence  the  fibres  may  be  called  the  pyramidal  fibres  of  the  lateral  columns 
(^Fig.  132,  P,  P').  About  the  same  time  analogous  formations  appear 
in  the  anterior  columns,  one  on  each  side  of  the  median  fissure  which 
separates  the  anterior  root-zones.  These  bundles  are  very  variable  in  size 
and  form,  but  are  generally  wedge-shaped  or  elliptical ;  they  form  the 
outer  and  lesser  portion  of  the  anterior  pyramids  of  the  medulla,  but  do 
not  decussate  with  one  another.  They  are  called  the  columns  of  Tiirck, 
or  of  Lockhart  Clarke  ;  and  they  may  also  be  called  the  pyramidal 
fibres  of  the  anterior  columns  {Fig.  132,  T).  At  the  same  period  at 
which  these  bundles  begin  to  develop,  somewhat  similar  formations 
appear  between  the  posterior  root-zones,  one  on  each  side  of  the  posterior 
median  fissure,  and  these  are  called  the  columns  of  GoU  {Fig.  132,  G). 
The  anterior  white  commissure  {Figs.  134  to  140,  ac)  also  appears  at  the 
same  time,  that  is,  about  the  eighth  week.  A  most  important  point  to  notice 
in  connection  with  the  development  of  the  white  substance  is  that  the  fibres 
when  first  developed  are  destitute  of  a  medullary  sheath,  and  only  become 

Fig.  132, 


«■/?,  r/7 


— fie 


Fig.  132.  Cord  of  Human  Embryo  at  five  months.— ah,  ah',  anterior  horns  of  grey 
substance  ;  ph.  ph',  posterior  horns  of  grey  substance ;  ar,  ar',  anterior  root- 
zones  ;  pr,  pr',  posterior  root-zones ;  P,  P',  pyramidal  fibres  of  lateral  columns  ; 
T,  columns  of  Tiirck;  G,  columns  of  GoU;  dc,  dc',  direct  cerebellar  fibres; 
c,  anterior  commissure. 


I 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


53 


Fig.  133. 


meduUated  at  a  later  period  of  development.  The  law  of  development  already 
stated  might,  indeed,  have  led  us  to  anticipate  that  such  would  be  the  case. 
A  correlated  fact  is  that  the  fibres  of  the  bundles  which  are  first  formed 
develop  a  medullary  sheath  at  a  time  when  the  fibres  of  the  later-formed 
bundles  are  non-meduUated.  When  the  cord  of  a  human  embryo  is 
examined  at  the  end  of  the  fifth  month  it  will  be  found  that  the  pyramidal 
fibres  of  the  lateral  columns,  the  fibres  of  the  columns  of  Tiirck  and  of  the 
columns  of  Goll,  are  non-medullated  ;  while  the  fibres  of  the  anterior  and 
posterior  root-zones,  and  those  of  the  cerebellar  fibres  of  the  lateral 
columns,  are  medullated.  When  a  transverse  section  of  the  cord  is 
examined  iu  glycerine  after  hardening  in  chromic  acid,  the  bundles  com- 
posed of  the  non-medullated  fibres  will  be  found  to  transmit  the  light 
more  readily  than  those  composed  of  the  medullated  fibres,  so  that  the 
section  exhibits  the  appearances  represented  {Fig.  \Z2)  in  the  cervical 
region  of  the  cord  of  a  human  embryo  at  the  fifth  month.  Even  when 
examined  by  the  naked  eye  after  hardening  in  chromic  acid  the  bundles 
composed  of  non-medullated  fibres  are  seen  to  be  of  a  much  darker  colour 
than  the  bundles  constituted  of  medullated  fibres  ;  and  the  former  also 
become  much  more  deeply  stained  with  carmine  than  the  latter.  The 
bundles  composed  c^f  the  non-medullated  fibres  are,  indeed,  to  the  naked 
eye  and  in  their  reactions  to  staining  fluids,  more  like  the  grey  than  the 
white  substance  of  the  adult  cord. 

The  Accessory  Portion  of  the  White 
Substance.  —  Inasmuch  as  the  greater 
part  of  the  fibres  of  the  anterior  and 
posterior  root-zones,  as  well  as  those 
of  the  direct  cerebellar  tract,  are  me- 
dullated as  early  as  the  fifth  month  of 

embryonic  life,  it  may  be  presumed 

that  all  of  them  are  fully  developed 

at  birth.     The  case,  however,  is  dif- 
ferent with  regard  to  the  fibres  of  the 

pyramidal  tract,  some  of  them  being 

medullated    and   fully    developed    at 

the   ninth   month  of  embryonic  life, 

while  others  are  not.    The  fibres  of 

the  columns  of  Goll  are  probably  also 

not  all  fully  developed  at  birth.    The 

fibres  of  the  pyramidal  tract  in  the 

cord  are  separated  by  the  septse  of 

neuroglia  and  the  branching  vessels  into 

small  lozenge-shaped  spaces  (i^i^r.  133).      ^j^.  133,  Transverse  Section  of  a 

The  later-formed  fibres  appear  to  in-  portion  of  the  Pyramidal  Tract 

sinuate  themselves  from  above  down-  rnagnified.-l    Tihv^s   of   large 

diameter  ;  2,  fibres  of  small  dia- 
wards    along    the    margins    of   these  meter;  3,  Deiter's  cells ;  4,  twig 

spaces,  so  that  the  earlier-formed  fibres  ga5tt"^''oTttspUi:i  ctd"" 


54) 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


occupy  their  centres  ;  the  older  being  therefore  further  removed  from  the 
blood-vessels  than  the  younger  fibres.  It  may  be  assumed  that  the  earlier- 
formed  fibres  connect  the  cortex  of  the  brain  with  the  earlier-formed  or 
fundamental  ganglion  cells  of  the  anterior  horns,  while  the  later-formed 
fibres  connect  the  cortex  with  the  accessory  cells.  What  has  already  been 
said  with  regard  to  the  size  of  the  ganglion  cells  as  a  test  of  the  stage  of 


Fig.  134. 


ar 


Fig.  134.  Middle  of  Lumbar  Enlargement.  Section  of  Spinal  Cord  from  the  middle  of 
the  Lumbar  Enlargement. — A  P,  anterior  and  posterior  grey  cornua  respec- 
tively ;  SG,  substantia  gelatinosa ;  cc,  central  canal ;  ac,  pc,  anterior  and 
posterior  commissure  respectively ;  G,  column  of  GoU ;  pr,  posterior  root-zone  ; 
p,  posterior  root ;  p',  external  radicular  fasciculus ;  p'r,  internal  radicular 
fasciculus;  a,  a,  a,  anterior  roots ;  ar,  a?*',  anterior  root-zone;  fr,  formatio 
reticularis  ;  pt,  pyramidal  tract ;  T,  column  of  Tiirck, 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 


55 


development  of  the  cell  is  equally  true  with  respect  to  the  diameter  of  the 
meduUated  fibres.  The  diameter  of  these  fibres  may  be  accepted  as  a 
rough  test  of  the  age  of  the  fibres  during  the  period  of  development,  but 
no  longer.  It  is  very  probable  that  the  small  meduUated  fibres  of  the 
pyramidal  tract  connect  together  the  small  cells  of  the  anterior  horns  and 
relatively  small  cells  in  the  cortex  of  the  brain  ;  while  on  the  contrary  the 
thick  fibres  connect  the  large  ganglion  cells  of  the  anterior  horns  and  large 
cells  of  the  cortex.  The  largest  cells  of  the  spinal  cord,  for  instance,  are 
found  in  the  lumbar  region,  and  the  largest  in  the  cortex  of  the  brain  in  the 
paracentral  lobule — the  centre  of  the  movements  of  the  leg — and  it  is  pro- 
bable that  these  cells  are  connected  with  each  other  by  thick  fibres.     We 


Fig.  135.  Upper  end  of  Lumhar  Enlargement. — The  letters  indicate  the  same  as  the 
corresponding  ones  in  Fig.  134. 

have  already  seen  that,  as  a  rule,  the  accessory  are  smaller  than  the  funda- 
mental ganglion  cells  of  the  anterior  horns,  and  it  may  therefore  be  in- 
ferred that  the  accessory  fibres  of  the  pyramidal  tract  are  as  a  rule  smaller 
than  the  fundamental  ones.  The  smaller  fibres  are  found  in  greater 
numbers  in  the  internal  and  posterior  part  of  the  lateral  column,  the 
portion  of  the  white  column  which  adjoins  the  grey  substance.  At  this 
spot  the  septa  of  connective  tissue  are  larger,  the  neuroglia  is  more 


5Q 


ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION. 


spongy,  and  the  lozenge-shaped  spaces  already  described  (Fig.  133)  are 
more  distinctly  marked  than  in  the  more  external  layers  of  the  white 
substance.  The  formatio  reticularis  of  the  spinal  cord  appears  indeed 
to  owe  its  structural  peculiarities  mainly  to  the  fact  that  it  consists 
in  great  part  of  longitudinal  fibres  of  small  diameter  separated  into 
bundles  by  comparatively  large  septa  of  loose  neuroglia.  This  portion 
of  the  cord  also  transmits  fibres  which  issue  from  the  grey  substance  to 
ascend  in  the  pyramidal  tract,  and  from  the  vesicular  column  of  Clarke  to 
pass  out  to  the  direct  cerebellar  tract.  But  the  longitudinal  fibres  of  small 
diameter,  which  are  so  abundant  in  this  portion  of  the  cord,  would  appear 
to  belong  to  the  accessory  portion  of  the  pyramidal  tract.    Indeed,  the 

Fig.  136. 


Fig.  136.  Lower  end  of  Dorsal  Region. — T,  column  of  Tiirck ;  dc,  direct  cerebellar 
tract.    The  other  letters  indicate  the  same  as  the  corresponding  ones  in  Fig.  134. 


spongy  character  of  the  neuroglia  and  the  vascularity  of  this  area  render 
it  peculiarly  adapted  for  the  growth  of  new  fibres.  The  fibres  of  the 
columns  of  GoU  are  also  separated  by  the  distribution  of  the  blood-vessels 
and  septa  of  connective  tissue  into  lozenge-shaped  spaces.  The  fibres  at 
the  margins  of  these  spaces  are  not  meduUated  at  nine  months  of  embryonic 
life,  and  they  are  as  a  rule  less  in  diameter  in  the  adult  cord  than  the 
fibres  which  occupy  the  centres  of  the  spaces.  These  small  fibres  must 
therefore  be  regarded  as  belonging  to  the  accessory  system.  The  fibres  of 
the  posterior  root-zones  are  smaller  than  those  of  the  anterior  and  lateral 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


57 


columns,  with  the  exception  of  some  of  the  accessory  fibres  of  the  pyramidal 
tract.  The  reason  of  this  appears  to  be  that  the  fibres  of  the  posterior 
root-zones  connect  the  cells  of  the  posterior  horns  with  each  other,  and 
the  latter  being  themselves  small  the  intercommunicating  fibres  are  also 
small. 

§  372.  Longitudinal  Distribution  of  the  White  Substance. 
These,  then,  are  the  component  parts  of  the  spinal  cord, 
considered  with  reference  to  its  transverse  section ;  the  longi- 
tudinal distribution  of  these  parts   must  now  be  described. 


Fig.  137.  Middle  of  Dorsal  Region. 

The  grey  matter  extends  the  whole  length  of  the  cord,  and  its 
size  maintains  a  constant  relation  to  the  number  and  variety 
of  the  movements  to  be  co-ordinated ;  hence  it  is  larger  in  the 
lumbar  and  cervical  regions,  where  the  movements  of  the 
limbs  are  co-ordinated.  The  anterior  and  posterior  root-zones 
also  extend  the  whole  length  of  the  cord,  and,  speaking 
broadly,  their  size  maintains  a  pretty  constant  relation  to  the 


58 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 


size  of  the  grey  matter,  although  there  is  probably  a  slight 
increase  of  size  from  below  upwards.  The  most  noticeable 
feature  with  regard  to  the  remaining  bundles  of  fibres  is,  that 
they  increase  steadily  in  size  from  below  upwards.  The  fibres 
of  Goll  (Figs.  134  to  140,  G)  extend  the  whole  length  of  the 
cord,  but  they  gradually  diminish  in  size  from  the  medulla,  so 
that  mere  traces  of  them  are  to  be  found  in  the  lumbar  region. 
The  pyramidal  fibres  of  the  lateral  columns  {Figs.  134  to  140, 2^t) 
also  extend  the  whole  length  of  the  cord,  but  steadily  diminish 

Fia.  138. 


Fig.  138.   Upper  end  of  Dorsal  Begion. 


in  size  from  above  downwards,  so  that  they  are  reduced  to 
comparatively  small  bundles  in  the  lumbar  region.  The  direct 
cerebellar  fibres  of  the  lateral  columns  {Figs.  136  to  140,  dc) 
appear  in  the  cervical  region  as  thin  lamellae  of  fibres,  one  on 
each  side,  external  to  the  pyramidal  fibres.  They  diminish 
in  size  from  above  downwards,  and  disappear  somewhat  below 
the  middle  of  the  dorsal  region,  so  that  in  the  lower  dorsal  and 


ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 


59 


lumbar  regions  the  pyramidal  fibres  come  to  the  surface  of  the 
cord.  The  fibres  of  Turck  {Figs.  136  to  140,  T)  also  diminish 
in  size  from  above  downwards,  and  disappear  about  the  middle 
of  the  dorsal  region. 

The  relative  size  and  position  of  the  different  segments  of 
the  white  substance  may  be  seen  in  Figs.  134  to  140,  which 

Fig.  139. 


Fig.  139.  Middle  of  Cervical  Enlargement. 


represent  sections  of  the  spinal  cord  of  a  nine  months  human 
embryo  at  different  elevations.  The  fibres  of  the  pyramidal 
tracts  (pt)  of  the  lateral  columns,  and  of  the  columns  of  Goll 
(G)  and  of  Tiirck  (T),  have  assumed  a  medulla  at  the  ninth 
month,  and  are  not,  therefore,  so  distinctly  marked  off  from 
the  remaining  portions  of  the  white  substance  as  they  are 


60 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 


represented  in  the  figures,  the  latter  being  in  this  respect  more 
like  the  appearances  presented  by  the  cord  between  the  fifth 
and  sixth  months  of  embryonic  life,  at  a  time  when  the  fibres  of 
the  anterior  and  posterior  root-zones  and  the  direct  cerebellar 
tract  are  alone  medullated. 


Fig.  140.  Section  on  a  level  with  the  Second  Cervical  Nerve.  —  sa,  Spinal  accessory 
nerve.  The  other  letters  indicate  the  same  as  the  corresponding  ones  in 
Figs.  134  and  136. 

§  373.  Continuation  upward  of  the  various  Segments  of  the 
White  Substance  of  the  Cord  through  the  Medulla, 
Pons,  and  Cms  Cerebri. 
(1)  Columns  of  Goll  and  Posterior  Root-zones. — A  trans- 
verse section   of  the   lower  half  of  the  medulla  shows  that 
the  columns  of  Goll  are  continued  upwards  into  the  medulla 


ANATOMICAL  AND  PHYSIOLOGICAL   INTEODUCTION.  61 

in  the  form  of  two  bundles  of  fibres,  one  on  each  side  of  the 
posterior  median  fissure.  Each  bundle  contains  a  nucleus  of 
grey  matter,  which  from  its  form  is  called  the  clavate  nucleus, 
and  the  bundle  itself  is  called  the  pyramidal  column,  or 
fasciculus  gracilis  (Fig.  122,  G,  en).  External  to  this  fasciculus 
is  placed  a  wedge-shaped  bundle,  called  the  fasciculus  cuneatus, 
holding  in  its  interior  a  grey  nucleus,  called  from  its  form  the 
triangular  nucleus  (Fig.  122,  pr,  tn).  The  greater  portion  of 
the  fibres  of  the  posterior  root-zone  of  the  cord  terminates  in 
the  cuneate  fasciculus  and  its  enclosed  grey  nucleus.  The 
slender  and  cuneate  fasciculi  of  the  medulla  are  much  larger  in 
size  than  the  column  of  Goll  and  posterior  root-zone  of  the 
cord,  owing  to  the  interposition  of  the  grey  nuclei ;  hence  the 
posterior  horn  of  grey  matter  is  displaced  outwards  and  forwards 
in  the  medulla,  so  that  the  continuation  of  the  gelatinous  sub- 
stance forms  a  mass  of  grey  matter  on  the  lateral  aspect  of  the 
medulla,  known  as  the  grey  tubercle  of  Rolando  (Fig.  122,  sg). 
This  mass  of  grey  matter  is  continued  upwards  in  the  medulla 
and  pons  to  the  level  of  the  point  of  emergence  of  the  fifth 
nerve,  and  gives  origin  to  the  ascending  root  of  the  latter. 
In  close  relationship  with  the  external  surface  of  this  grey 
mass  is  a  bundle,  the  fibres  of  which  are  medullated  in  a 
nine  months  embryo.  This  bundle  is  the  homologue  in  the 
medulla  of  the  posterior  root-zone  of  the  cord,  and  is  frequently 
found  diseased  in  locomotor  ataxy  (Figs.  122  to  127,  at). 

One  of  the  most  remarkable  rearrangements  of  fibres  in  the 
medulla  arises  from  the  fact  that  the  cuneate  fasciculus,  through 
the  intermediation  of  its  nucleus,  resolves  itself  into  arcuate 
fibres,  which  pass  forwards  and  upwards  to  be  connected  with 
the  nucleus  of  the  olivary  body  on  the  same  side;  and  it  is 
also  probable  that  the  slender  fasciculus  through  its  nucleus  has 
a  similar  termination. 

A  transverse  section  of  the  upper  part  of  the  medulla  shows 
that  the  fibres  have  undergone  a  still  further  rearrangement, 
and  that  they  are  greatly  reinforced  in  number ;  but  the  course 
of  the  additional  fibres  will  be  more  readily  traced  if  we  follow 
them  from  the  cerebellum  to  the  medulla,  instead  of  from  below 
upwards. 

(2)  ConTiections  of  the  Peduncles  of  the  Cerebellum  with 


62         ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION. 

the  Medulla  Oblongata,  Pons,  and  Crura  Cerebri. — The  in- 
ferior 'peduncle  of  the  cerebellum,  according  to  Stilling,  breaks 
up,  on  entering  the  medulla,  into  an  internal  {Fig.  125,  ep)  and 
an  external  {Fig.  125,  iii)  division,  the  latter  of  which  he  called 
the  "restiform  body."  The  fibres  of  the  internal  division 
spring  from  the  roof-nuclei  of  Stilling,  and  on  reaching  the 
medulla  resolve  themselves  into  arcuate  fibres,  which  pass 
downwards  and  inwards,  interlacing  with  the  ascending  fibres 
of  the  anterior  root-zone  behind  the  olivary  body  of  the  same 
side  ;  and  some  anatomists  believe  that  they  cross  the  median 
raphe  to  reach  the  olivary  body  of  the  opposite  side.  The 
fibres  of  the  restiform  body  are  derived  from  the  cortex  of  the 
cerebellum,  and  from  a  layer  of  fibres  surrounding  the  dentate 
nucleus  ;  and  this  division,  on  descending  to  the  medulla,  sub- 
divides into  two  bundles,  which  are  separated  from  one  another 
by  the  direct  cerebellar  fibres  of  the  lateral  columns  of  the 
cord  in  their  ascent  towards  the  cerebellum  {Fig.  125,  dc).  In 
a  nine  months  human  embryo  the  fibres  of  the  restiform  body 
are  non-medullated  {Fig.  125,  ep) ;  while  those  ascending  from 
the  lateral  columns  are  medullated  {Fig.  125,  dc),  so  that  the  two 
sets  can  be  readily  distinguished  from  one  another.  The  fibres 
of  the  restiform  body,  like  those  of  the  internal  division  of  the 
peduncle,  resolve  themselves  into  arcuate  fibres ;  the  external 
bundle  forming  the  zonular  layer  which  passes  in  front  of  the 
olivary  body,  and  the  fibres  of  which  reach  the  median  raphe  by 
passing  both  in  front  and  behind  the  anterior  pyramid.  Those 
which  pass  in  front  of  the  anterior  pyramid  are  called  arciform 
fibres  {Fig.  125,  a) ;  they  wind  backwards  to  reach  the  median 
raph^  {Fig.  141),  where,  after  ducussating  with  the  correspond- 
ing fibres  of  the  opposite  side,  they  bend  outwards  to  reach 
the  olivary  body  of  the  opposite  side  where  they  terminate.  A 
great  part  of  the  arcuate  fibres  of  the  internal  bundle  seem 
to  pass  through  the  olivary  body  of  the  same  side  without  being 
connected  with  its  grey  substance  ;  and  after  gaining  the  raphe 
they  also  cross  over  to  pass  into  the  interior  of  the  olivary  body 
of  the  opposite  side,  in  the  grey  substance  of  which  all  the 
arcuate  fibres  of  the  restiform  body  terminate.  The  olivary 
body,  therefore,  is  the  medium  of  communication  between  the 
cuneate  fasciculus  and  probably  also  the  slender  fasciculus  of 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION. 


63 


the  same  side  on  the  one  hand,  and  the  restiform  body  and 
probably  the  internal  division  of  the  cerebellar  peduncle  of  the 
opposite  side  on  the  other  hand. 

The  fibres  of  the  middle  peduncle  of  the  cerebellum  are 
derived  from  the  cortex  ;  they  pass  in  front  of  and  through  the 
substance  of  the  pons  {Figs.  126  to  128,  Tt  and  Tr'),  where 
they  separate  the  ascending  fibres  of  the  anterior  pyramids 
into  bundles  {Figs.  126  to  128,  P,  p),  and  interlace  in  the 
middle  line  with  the  fibres  of  the  middle  peduncle  of  the 
opposite  side.  On  reaching  the  opposite  side  they  are  supposed 
to  terminate  in  the  cells  of  interposed  grey  matter,  by  means 
of  which  they  are  connected  with  fibres  descending  from  the 
crusta.  The  close  relationship  of  the  middle  peduncles  with 
the  lateral  lobes  of  the  cerebellum  is  well  illustrated  by  the 
fact  that  in  those  animals  in  which  the  latter  are  deficient  or 
absent  the  transverse  fibres  of  the  pons  are  few  or  entirely 
wanting. 

Fig  141. 


^'^y 


FtG.  141  (Prom  Henle''s  "Anatomle").  hiayrmn  of  a  horizontal  stction  of  the 
anterior  part  of  the  median  rctph4qf  tliie  Medulla  OMcngata. — Fpy,  Anterior 
pyramid  j  Fba,  Fibrse  arciformea. 


64         ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION. 

The  fibres  of  the  superior  peduncles  are  derived  from  the 
dentate  nuclei ;  they  decussate  with  one  another  in  the 
tegmentum,  the  fibres  of  one  side  passing  over  to  be  connected 
with  the  red  nucleus  of  the  opposite  side  {Fig.  129,  x).  The 
fibres  of  the  superior  peduncles  are  medullated  in  a  nine 
months  embyro ;  they  may  be  seen  surrounding,  and  even  in, 
the  substance  of  the  red  nucleus  {Fig.  129,  RJ^T),  and  a  con- 
siderable proportion  of  them  pass  upwards  uninterruptedly 
into  the  tegmental  portion  of  the  internal  capsule,  and  either 
end  in  the  inferior  or  external  surface  of  the  thalamus,  or,  as 
I  am  inclined  to  believe,  pass  uninterruptedly  along  its  external 
border  upwards  to  be  connected  with  the  central  convolutions 
of  the  cortex  of  the  cerebrum. 

Some  anatomists  think  that  part  of  the  fibres  of  the  anterior 
root-zones  pass  through  the  crusta  to  join  the  lenticular  nuclei; 
but  a  very  important  fact  has  been  ascertained  by  Flechsig, 
which  renders  this  doubtful.  Flechsig  found  that  in  a  nine 
months  human  embryo  the  pyramidal  fibres  in  the  crusta  are  the 
only  ones  which  have  acquired  a  medullary  sheath  ;  and  my  own 
sections  confirm  this  {Fig.  129,  P).  But  the  fibres  of  the  anterior 
root-zones  in  the  cord  are  medullated  at  a  very  early  period  of 
development,  and  long  before  the  pyramidal  fibres  have  acquired 
a  medullary  sheath ;  hence  it  may  be  inferred  that  none  of  the 
fibres  of  the  anterior  root-zones  pass  up  into  the  crusta  or 
niotor  tract  of  the  crura,  although  it  is  very  probable  that  new 
fibres  become  developed,  which  connect  the  corpora  striata  and 
the  cord,  and  that  these  pass  through  the  crusta  and  become 
mixed  with  the  fibres  of  the  anterior  root- zones.  The  close 
connection  which  is  maintained  between  the  anterior  root-zones 
and  that  portion  of  the  central  grey  tube  which  is  in  immediate 
relation  with  the  efferent  nerves,  seems  to  indicate  that  the 
former  consist  of  fibres  which  co-ordinate  the  various  segments 
of  the  cord  longitudinally ;  and  there  are  other  grounds  for 
believing  them  to  consist  of  a  series  of  looped  fibres  which 
originate  and  terminate  in  the  anterior  part  of  the  central  grey 
tube. 

(3)  The  direct  cerebellar  fibres  are  represented  by  a  thin 
lamella  of  longitudinal  fibres  lying  on  the  surface  of  the  cuneate 
fasciculus  and  of  the  grey  tubercle  of  Rolando  {Figs.  124  and 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.  65 

125,  dc).  They  pass  upwards  to  the  cortex,  and  thus  form  an 
uninterrupted  connection  between  its  grey  matter  and  the  cord, 
where  the  fibres  are  supposed  to  pass  inwards  between  the 
bundles  of  the  pyramidal  fibres  of  the  lateral  columns,  to 
terminate  in  the  cells  of  the  group  known  as  Clarke's  column. 
Their  function,  however,  is  not  yet  ascertained. 

(4)  Tlie  Pyramidal  Tract. — The  pyramidal  fibres  of  the 
lateral  columns  at  the  upper  end  of  the  cervical  region  of  the 
cord  pass  forwards  and  inwards  towards  the  anterior  median 
fissure.  These  fibres  decussate  with  one  another  in  the 
medulla,  so  that  those  of  the  right  side  pass  to  the  left,  and 
those  of  the  left  to  the  right.  The  decussation  frequently  begins 
in  the  upper  portion  of  the  cord;  while  the  homologues  of 
the  pyramidal  fibres,  which  arise  from  the  nerve-nuclei  of  the 
hypoglossal  and  facial  nerves,  cross  separately  in  the  pons 
above  the  decussation  of  the  pyramids.  The  pyramidal  fibres 
of  the  lateral  columns  during  and  subsequent  to  their  decus- 
sation come  forwards  into  the  anterior  median  fissure,  and 
push  aside  the  columns  of  Tiirck  {Fig.  140,  T),  so  that  the  latter 
form  a  prismatic  bundle  of  fibres  external  to  the  former,  and 
ascend  without  decussating  with  one  another.  These  two  sets 
of  fibres  constitute  the  anterior  pyramids  of  the  medulla  {Figs. 
122  to  125,  P) ;  they  can  be  traced  through  the  pons  {Figs.  126 
to  128,  P),  where  they  receive  a  large  accession  to  their  size, 
into  the  peduncles  of  the  cerebrum.  According  to  the  researches 
of  Flechsig,  which  my  own  sections  confirm,  the  pyramidal 
fibres,  after  being  separated  into  distinct  bundles  in  the 
pons,  come  together  so  as  to  form  one  compact  bundle  in 
each  peduncle  {Fig.  1 29,  P).  This  bundle  occupies  about  the 
middle  third  of  the  crust  of  the  cerebral  peduncle,  and, 
contrary  to  what  has  hitherto  been  believed,  it  passes  into 
the  posterior  segment  of  the  internal  capsule,  lying  between 
the  lenticular  nucleus  and  optic  thalamus  opposite  the  middle 
third  of  the  latter.  The  pyramidal  bundle  is  separated  from 
the  caudate  nucleus  by  a  layer  of  fibres,  which  ascend  from  the 
external  surface  of  the  optic  thalamus  to  reach  the  corona 
radiata,  while  it  rests  on  the  three  successive  segments  of  the 
lenticular  nucleus,  and  reaches  the  corona  radiata  opposite  the 
third  quarter  of  the  caudate  nucleus  (reckoning  from  before 

F  . 


66 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


backwards).  Having  emerged  from  between  the  basal  ganglia, 
without  anywhere  communicating  with  them,  the  fibres  of  the 
pyramidal  bundle  radiate  in  all  directions  towards  the  surface 
of  the  cerebrum,  and  are  mainly  distributed  to  the  central 
convolutions  about  the  sulcus  of  Rolando,  the  so-called  "  motor 
area"  of  the  cortex  (Fig.  142,  P"). 


Fig.  142  'After  Flechsig).     Diagram  of  the  Grey  Masses  of  the  Spinal  Cord  and 
Brain,  showing  the  course  of  the  Conducting  Paths. 

It,  Fissure  of  Rolando. 

P"  P,  T  and  Ft,  Course  of  the  fibres  of   the  pyramidal  tract  from  their 

origin  in  the  central  convolutions  to  their  termination  in  the  anterior  grey 

horns  (a,  a'). 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.  67 

The  cardinal  facts  which  concern  us  at  present  are,  that 
fibres  issue  from  the  central  convolutions  of  the  cerebrum, 
which  pass  through  the  internal  capsules  without  communicating 
with  the  basal  ganglia ;  that  the  same  fibres  pass  through  the 
cerebral  peduncles  to  enter  the  pons,  where  they  at  once  begin 
to  diminish  in  number.  The  fibres  of  this  kind,  which  pass 
through  the  pons,  collect  together  to  form  the  anterior  pyramids 
of  the  medulla,  which  also  diminish  iu  size  from  above  down- 
wards, showing  that  some  of  these  fibres  are  lost  in  the  medulla 
itself  The  internal  and  by  far  the  larger  portion  of  the 
pyramids  decussate  with  one  another,  and  these  portions  pass 
backwards  so  as  to  form  in  the  cord  the  bundles  of  pyramidal 
fibres  in  the  lateral  columns — bundles  which  extend  the  whole 
length  of  the  cord,  but  gradually  diminish  from  above  down- 
wards. The  external  and  lesser  portion  of  the  pyramids  pass 
directly  downwards  to  form  the  columns  of  Tiirck — columns 
which  dwindle  gradually  until  they  disappear,  usually  about  the 
middle  of  the  dorsal  region.  It  is  not  yet  proved  anatomically 
how  these  fibres  end  in  the  cord ;  but  other  considerations 
render  it  probable  that  they  end  in  the  grey  matter  of  the 
anterior  horns  and  its  continuation  through  the  medulla,  pons, 
and  around  the  aqueduct  of  Sylvius.  The  pyramidal  fibres,  in 
one  word,  form  an  uninterrupted  connection  between  the  central 
convolutions  of  the  brain  and  the  central  grey  tube  of  the 
cord. 


/,  //,  ///,  First,  second,  and  third  portions  of  the  lenticular  nucleus  (NL'. 

NC,  Caudate  nucleus.      Th,  Optic  thalamus. 
D,  C,  B,  A,  Points  from  which  fibres  issue  connecting  the  cortex  of  the  brain 

and  basal  ganglion,  and  also  the  grey  substance  of  the  pons  (PO).     Bd, 

Fibres  connecting  the  cerebellum  and  optic  thalamus ;    and  Cap,  those 

connecting  the  cerebellum  and  the  grey  substance  of  the  pons. 
aq,  &n.di  pq,  Anterior  and  posterior  pair  of  corpora  quadrigemina  respectively. 
X,  Upper,  and  x',  lower  fibres  connecting  the  olivary  body  and  the  corpora 

quadrigemina. 
FR,  Formatio  reticularis  of  the  medulla  oblongata,  formed  by  fibres  from  the 

optic  thalamus  [Th],  the  internal  division  of  the  inferior  peduncle  of  the 

cerebellum  [icp),  from  the  spinal  cord  (fr,  ar,  and  a/),  and  probably  also 

from  the  clavate  nucleus  {Nc). 
o,  Olivary  body ;   ecp,  Fibres  of  the  restiform  bodies  connecting  the  olivary 

bodies  and  cerebellum  ;  other  fibres  connect  it  with  the  triangular  (Npr) 

and  clavate  (NC)  nuclei. 
(IP,  Decussation  of  the  pyramids. 
pr'.  Fibres  of  the  ijosterior  roots  which  pass  upwards  and  downwards  into  the 

grey  substance,  and  pursue  only  a  short  course. 
a,  a',  a",  a"',  a"",  Anterior  roots. 
p,  pr,  pr',  pjr",  G,  Fibres  of  the  posterior  roots. 


68 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 


The  Accessory  Portion  of  the  Pyramidal  Tract. — We  have 
seen  that  the  accessory  fibres  of  the  pyramidal  tract  occupy 
the  margins  of  the  lozenge-shaped  spaces  into  which  the  lateral 
column  and  column  of  Turck  are  divided  (i^^^.  183),  and  that  they 
are  very  abundant  in  the  portion  of  the  lateral  column  which 
adjoins  the  grey  substance,  and  especially  in  the  formatio 
reticularis.  But  on  ascending  to  the  anterior  pyramid  of  the 
medulla  the  accessory  fibres  become  much  more  abundant,  and 

Fig.  143. 


Fig.  143.  (After  Flechsig).     Diagram  of  Transverse  Section  of  the  Spinal  Cord  in 
upper  Imlf  of  the  Dorsal  Region. 

C,  Anterior  commissure. 

M,  Fibres  which  pass  from  the  vesicular  column  of  Clarke  'vc)  to  the  direct 

cerebellar  tract. 
P,  Posterior  horn. 

Figs.  142  and  143  (After  Flechsig).— Letters  common  to  Figs.  141  and  142. 

Pt,  Pyramidal  tract  of  the  lateral  column. 

T,  Columns  of  Tiirck. 

dc,  Direct  cerebellar  tract. 

ar.  Internal  portion  of  the  anterior  root-zone. 

ar',  External  portion  of  the  anterior  root-zone. 

pr.  Posterior  root-zone. 

G,  Goll's  columns. 

fr,  Reticular  formation  of  the  spinal  cord. 

a,  Anterior  grey  horns  of  the  spinal  cord. 


I 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.  69 

although  some  of  them  may  still  mix  with  the  other  fibres, 
they  aggregate  in  the  internal  and  anterior  margin  of  the 
pyramid,  so  as  to  occupy  a  circumscribed  area  of  the  pyramid 
without  admixture  with  other  fibres.  This  area  is  shown  in 
Figs.  124  and  125,  p,  which  represent  sections  of  the  medulla  of 
a  nine  months  embryo.  On  passing  through  the  pons  the  non- 
medullated  fibres  occupy  the  inner  portion  of  the  longitudinal 
fasciculi  {Figs.  126  to  128,  p),  pass  to  the  inner  side  of  the 
medullated  fibres  in  the  crust  of  the  crus  cerebri  (Fig.  129,  p), 
and  reach  the  cortex  mainly  by  passing  through  the  anterior 
half  of  the  internal  capsule. 

(5)  The  Anterior  Root-zones. — The  continuation  of  the 
anterior  root-zones  through  the  medulla,  pons,  and  crus, 
deserves  special  attention.  The  course  of  the  fibres  of  these 
zones  in  the  medulla  is  obscured  by  the  fact  that  they  do 
not  form  a  defined  mass,  as  in  the  cord.  They  are  separated 
into  bundles  by  the  arcuate  fibres  of  the  medulla,  so  as  to 
form  what  is  called  from  its  reticular  appearance  the  formatio 
reticularis  (Fig.  125,  frs).  The  zones  consist  of  two  portions, 
an  internal,  which  lies  between  the  anterior  median  fissure 
and  the  anterior  roots  (Figs.  134  to  140,  ar),  and  an  external, 
consisting  of  the  remaining  portion  {Figs.  134  to  140,  ar'). 
The  internal  portions  of  the  anterior  root-zones  are  pushed 
aside  in  the  lower  part  of  the  medulla  by  the  decussating  fibres 
of  the  pyramidal  tract,  but  above  the  level  of  the  decussation, 
where  the  olivary  body  is  intercalated,  the  internal  portion 
is  thrust  backwards  behind  the  pyramids  and  close  to  the 
median  raphd,  while  the  fibres  of  the  hypoglossal  nerve  separate 
the  internal  from  the  external  portion  of  the  anterior  root-zone. 
In  the  spinal  cord  the  internal  portion  of  the  anterior  root-zone 
maintains  a  close  relation  to  the  internal  group  of  ganglion 
cells,  and  this  relation  is  apparently  maintained  throughout  its 
course  in  the  medulla,  pons,  and  crus.  The  portion  which  is 
called  the  posterior  longitudinal  fasciculus  in  the  medulla 
{Figs.  124  to  128,  L),  pons,  and  crus,  appears  to  be  the  con- 
tinuation upwards  of  the  part  of  the  internal  portion  of  the 
anterior  root-zone  which  adjoins  the  grey  matter,  and  this 
fasciculus  always  lies  to  the  inner  side  of  the  roots  of  the 
anterior  motor  nerves,  at  their  origin  in  the  motor  ganglion 


70         ANATOMICAL  AND  PHYSIOLOGICAL  INTKODUCTION. 

cells.  The  upward  continuation  of  the  part  of  the  internal 
portion  of  the  anterior  root-zone  which  is  remote  from  the  grey 
matter  is  represented  by  ar  in  Figs.  124  to  129. 

In  the  crus  the  posterior  longitudinal  fasciculus  is  situated  in 
front  of  the  aqueduct  of  Sylvius,  in  close  relationship  with  the 
nucleus  of  origin  of  the  third  nerve  (i^i^.  129,  Z).  A  portion  of  this 
bundle  is  continued  forwards  in  the  thalamus  in  the  walls  of 
the  lateral  ventricle,  while  the  remaining  fibres  bend  backwards 
to  join  the  posterior  commissure  of  the  third  ventricle.  The 
fibres  of  the  latter  portion  are  the  first  to  become  medullated 
in  the  cerebrum  of  the  human  embryo. 

The  external  portion  of  the  anterior  root-zone  of  the  cord  is 
continued  upwards  into  the  formatio  reticularis  of  the  medulla 
{Figs.  12-i  to  128,  ar').  The  continuation  of  the  external 
portion  of  the  anterior  root-zone  lies  behind  the  olivary  body, 
and  comes  to  the  surface  of  the  medulla  in  its  lateral  column. 
It  is  bounded  internally  by  the  root  fibres  of  the  anterior  motor 
nerves,  and  externally  by  the  root  fibres  of  the  nerves  of  the 
lateral  mixed  system,  and  posteriori)'-  by  grey  matter.  The 
interlacing  fibres  of  the  pons  {Figs.  126  to  128,  Tr)  pass  in  front 
of  this  portion  (ar'),  while  in  the  crus  the  latter  comes  again 
further  forwards,  the  locus  niger  lying  between  it  and  the  crust 
{Fig.  129,  ar). 

(III). -FUNCTIONS    OF   THE    SPINAL    CORD    AND    MEDULLA 
OBLONGATA. 

It  would  occupy  too  much  space  to  describe  fully  the  func- 
tions of  the  spinal  cord  and  medulla  oblongata,  and  the  reader 
is  referred  to  physiological  manuals  for  the  usual  information 
on  the  subject.  My  main  object  at  present  is  to  elicit  a  few 
points  which  will  be  of  subsequent  use  to  us  in  interpreting 
the  phenomena  of  disease,  and  in  connecting  symptoms  with 
morbid  alterations  of  structure. 

§  374.  Voluntary  Action. — The  special  functions  of  the  cord 
are  those  by  which  the  spinal  centres  are  subordinated  to  the 
motor  centres  of  the  cortex  of  the  brain.  It  is  probable  that 
all  the  spinal  centres  are  connected  with  the  motor  centres  of 
the  cortex  of  the  brain,  or  are,  in  other  words,  under  voluntary 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.  71 

control ;  but  the  later-acquired  movements  of  man  are  more 
thoroughly  under  voluntary  guidance  than  the  earlier-acquired 
or  fundamental  actions.  Inasmuch  as  the  observation  of  the 
development  of  the  cord  has  enabled  us  to  draw  a  broad  dis- 
tinction between  the  fundamental  and  accessory  portions  of  the 
structure  of  the  spinal  cord,  it  will  be  well  to  endeavour  first  to 
connect  the  later-acquired  or  accessory  functions  with  the  later- 
acquired  or  accessory  structure.  The  earlier-acquired  or  funda- 
mental functions  will  then  be  left  as  a  residuum  to  be  con- 
nected with  the  fundamental  structure  of  the  cord. 

(1)  The  Accessory  Functions  of  the  Spinal  Cord  and  Medulla  Oblongata. 
The  movements  of  the  hand  afford  the  best  example  of  the  accessory- 
functions  of  the  spinal  cord.  These  movements  are  peculiar  to  man, 
and  by  far  the  greater  number  of  them  are  acquired  after  birth.  It 
may,  therefore,  be  expected  that  the  development  of  the  structure,  which 
represents  these  movements  in  the  spinal  cord,  must  also  take  place  after 
birth. 

The  movements  which  are  most  characteristic  of  the  upper  ex- 
tremity in  man  are  those  of  pronation  and  supination  of  the  forearm 
and  the  complicated  movements  of  the  hand  and  fingers,  and  it  is  exceed- 
ingly probable  that  the  structural  representatives  of  some  if  not  all  of 
these  movements  are  to  be  found  in  the  median  group  of  cells.  These 
cells  appear  at  a  late  period  of  the  development  of  the  cord,  hence  they 
form  a  speciality  of  structure  which  corresponds  to  some  speciality  of 
function ;  again  they  maintain  a  small  size  even  in  the  adult  cord,  and 
consequently  may  be  expected  to  preside  over  the  action  of  small  muscles, 
both  of  these  conditions  being  realised  in  the  hand. 

The  smaller  median  area  in  the  lumbar  enlargement  of  the  cord 
presides  probably  over  the  movements  of  the  lower  limbs,  which  dis- 
tinguish the  adult  man  from  the  lower  animals  and  also  from  the  human 
infant.  These  movements  are  mainly  executed  by  the  extensors  of  the 
leg  on  the  thigh  and  probably  also  by  the  adductors,  and  by  the  flexors  of 
the  foot  on  the  leg.  Indeed,  the  slight  elevation  of  the  ball  of  the  toe,  so 
as  to  allow  the  passive  leg  to  swing  forwards  by  its  own  weight  in  walking, 
is  the  last  movement  acquired  by  the  child ;  and  we  shall  subsequently 
sse  that  it  is  the  first  movement  to  be  affected  in  disease.  If,  then,  the 
median  area  of  small  cells  be  the  structural  correlative  of  the  later-acquired 
and  more  special  movements  of  the  limbs,  it  must  be  absent  in  those  por- 
tions of  the  cord  which  do  not  supply  nerves  to  limbs,  and  we  have  already 
seen  that  this  area  is  absent  in  the  dorsal  and  upper  cervical  regions  of 
the  cord. 

Tt  must  be  remembered  that  the  muscles  of  the  hand  are  connected 
with  the  earlier-formed  or  fundamental  cells  of  the  anterior  horns,  and 


72  ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

that  the  small  cells  of  the  median  area  do  not  of  themselves  suffice  for 
the  regulation  of  their  movements.  The  increased  development  of 
the  median  area  in  the  cervical  enlargement  represents  merely  a  com- 
plication on  the  previous  structure  of  the  cord  corresponding  to  the 
complication  of  muscular  adjustments  vrhich  distinguishes  the  hand  of 
man  from  the  anterior  extremity  of  animals. 

The  hypoglossal  accessory  nucleus,  and  the  internal  and  external 
accessory  facial  nuclei,  appear  to  be  the  homologues  in  the  medulla 
oblongata  of  the  median  area  in  the  cervical  and  lumbar  enlargements  of 
the  spinal  cord.  The  hypoglossal  accessory  nucleus  seems  to  be  the 
additional  structural  complication  rendered  necessary  by  the  compli- 
cated movements  executed  in  the  production  of  articulatory  speech  ;  while 
the  facial  accessory  nuclei  are  the  structural  counterparts  in  the  medulla 
of  the  movements  of  facial  expression. 

The  next  accessory  function  which  I  shall  mention  is  the  muscular 
adjustments  necessary  for  maintaining  the  erect  posture  in  man.  These 
adjustments  are  also  acquired  a  considerable  time  after  birth,  hence  it 
may  be  inferred  that  their  structural  counterpart  in  the  cord  is  not  well 
developed  at  birth.  The  medio-lateral  area  corresponds  in  my  opinion  to 
these  adjustments  in  the  dorsal  region  of  the  cord.  The  cells  of  this  area 
are  not  well  developed  at  birth,  and  the  area  is  entirely  absent  in  the 
lower  animals.  These  cells  are  also  of  small  size,  even  in  the  adult  cord, 
and  if,  as  we  have  already  stated,  the  size  of  the  ganglion  cell  is  related  to 
the  size  of  the  muscle  with  which  it  is  connected,  the  erectores  spines  are 
the  muscles  of  the  trunk  which  best  correspond  to  this  description.  The 
medio-lateral  area  appears  also  in  the  upper  cervical  region,  and  it  may 
be  presumed  that  the  small  muscles  which  extend  the  vertebral  column  in 
the  neck,  and  draw  back  and  rotate  the  head,  are  supplied  from  these 
cells.  We  have  already  seen  that  some  of  the  fibres  of  the  eleventh 
nerve  (spinal  accessory)  are  derived  from  the  postero-lateral  group  in  the 
cord,  and  it  is  very  probable  that  the  accessory  nucleus  of  this  nerve  in 
the  medulla  is  the  homologue  of  the  medio-lateral  area  in  the  upper  cer- 
vical and  dorsal  regions  of  the  cord.  The  accessory  nucleus  of  the 
eleventh  nerve  is  the  additional  organisation  rendered  necessary  by  the 
complicated  movements  of  the  human  larynx. 

The  marginal  cells  of  the  postero-lateral,  antero-lateral,  and  central 
groups  appear  late  in  the  development  of  the  cord,  and  these  therefore 
must  be  regarded  as  belonging  to  the  accessory  system,  even  although 
the  ganglion  cells  are  of  comparatively  large  size.  The  fact  that  these 
cells  are  of  large  size  shows  that  they  must  be  engaged  in  the 
regulation  of  the  movements  of  large  muscles.  It  is  probable  that 
these  marginal  cells  in  the  lumbar  region  regulate  the  contractions 
of  the  large  muscles  of  the  lower  extremity  which  are  engaged  in 
maintaining  the  erect  posture.  The  great  relative  size  of  the  gluteus 
maximus  in  man,  as  compared  with  the  lower  animals,  would  appear  to 
render  necessary  a  corresponding  increase  in  the  number  of  ganglion  cells 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.         73 

of  the  spinal  nucleus  which  regulates  its  movements  in  the  former,  as  com- 
pared with  that  in  the  latter.  And  inasmuch  as  the  gluteus  maximus  is  not 
much  called  into  action  until  a  considerable  time  after  birth,  these  super- 
added cells  must  belong  to  the  accessory  system.  These  additional 
cells  may  probably  be  represented  by  the  marginal  cells  of  the  postero- 
lateral group  in  the  lumbar  region.  The  alternate  upward  rotation  of  the 
pelvis  which  takes  place  in  walking,  and  which  is  mainly  effected  by 
contraction  of  the  gluteus  medius  and  minimus,  is  likewise  a  very  special 
movement  ;  and  it  also  may  be  regulated  by  the  later-developed  cells  of 
one  or  other  of  these  groups  of  ganglion  cells  in  the  anterior  horns. 

We  have  seen  that  the  postero-lateral  group  in  the  upper  cervical  region 
gives  off"  the  spinal  portion  of  the  spinal  accessory  nerve,  and  that  this  portion 
forms  the  external  branch  of  the  nerve,  which  is  distributed  to  the  sterno- 
cleido  mastoid  muscle  and  the  upper  portion  of  the  trapezius.  But  in  man 
the  sterno-cleido  mastoid  is  in  close  relation  with  the  clavicular  portion  of 
the  pectoralis  major,  being  only  separated  from  it  by  the  clavicle,  and  in 
those  animals  in  which  the  clavicle  is  deficient  it  runs  with  the  anterior 
part  of  the  trapezius  muscle  into  the  deltoid,  forming  a  mastoido-humeral 
muscle.  All  of  these  muscles  are  closely  associated  in  their  actions,  and 
it  is,  therefore,  probable  that  all  are  innervated  from  the  postero- 
lateral group,  while  the  latissimus  dorsi,  rhomboidei,  and  several  other 
muscles  may  perhaps  be  added  to  this  list.  It  is  very  probable  indeed 
that  the  muscles  which  may  be  compendiously  summed  up  with  reference 
to  their  functions  as  the  accessory  muscles  of  inspiration  are  innervated 
from  this  group  in  the  cervical  and  dorsal  regions.  These  muscles  are 
briefly  the  sterno-mastoids  and  scaleni,  the  pectoralis  major  and  minor, 
the  serrati  postici  et  superiores,  the  subclavius,  and  the  elevators  of  the 
head  and  spinal  column. 

The  postero-lateral  and  medio-lateral  groups  of  ganglion  cells  consist 
of  a  series  of  superimposed  ganglionic  centres,  constituting  a  column  of 
cells  which  extends  from  the  lumbar  region,  through  the  dorsal  and  cer- 
vical regions  of  the  cord  to  the  medulla  and  pons.  Speaking  broadly, 
this  column  regulates  the  muscular  contractions  necessary  for  the  main- 
tenance of  the  erect  posture,  the  contraction  of  the  extraneous  muscles  of 
respiration,  in  part  at  least  that  of  the  muscles  supplied  by  the  spinal 
accessory,  vagus,  glosso-pharyngeal,  seventh,  and  by  the  motor  branch 
of  the  fifth  nerves.  The  portion  of  the  facial  nerve  supplied  by  the 
continuation  of  the  postero-lateral'  group  in  the  medulla  probably  pre- 
sides over  the  function  of  the  facial  muscles  in  their  relation  with 
mastication  and  respiration.  The  series  of  superimposed  .ganglionic 
centres  of  which  the  postero-lateral  group  consists  cannot  act  inde- 
pendently of  each  other;  and  in  order  to  secure  harmony  of  action, 
some  of  these  centres  must  become  subordinate  to  other  centres,  either  of 
the  same  column  or  of  some  other  part  of  the  nervous  system.  All  of 
them  are  doubtless  co-ordinated  in  the  cortex  of  the  brain,  but  it  is  not 
improbable  that  the  inferior  centres  of  the  column  are  also  subordinated 


74         ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

to  one  of  the  superior  centres  in  tlie  medulla  oblongata.  If  such  should 
be  the  case,  there  is  no  occasion  for  assuming  the  existence  of  a  distinct 
respiratory  centre  in  the  medulla  oblongata  apart  from  the  upward  con- 
tinuation of  the  postero-lateral  column  of  cells.  It  is  much  more  pro- 
bable that  the  respiratory  centre  is  merely  an  enlargement  in  the  medulla 
of  the  postero-lateral  column  of  cells.  It  is  also  quite  likely  that  this  en- 
largement is  closely  connected  with  the  other  groups  of  cells  which  have 
been  continued  upwards  from  the  cord  into  the  medulla. 

(2)  Fundamental  Voluntary  Functions. — With  respect  to  the  functions 
of  the  antero-lateral  group,  I  must  content  myself  by  saying  very  little. 
The  cells  of  this  group  always  maintain  the  lead  in  the  course  of  develop- 
ment. It  is  not  only  that  they  begin  to  develop  and  assume  processes 
at  an  earlier  period  than  the  cells  of  the  other  groups,  but  the  greater 
portion  if  not  all  of  them  appear  almost  simultaneously,  and  maintain 
an  equal  rate  of  growth  during  development.  The  antero-lateral  differs  in 
this  respect  from  the  postero-lateral  and  central  groups,  which  increase 
in  size  by  the  gradual  addition  of  new  ganglion  cells  at  their  margins.  It 
may  be  expected,  therefore,  that  this  group  will  regulate  the  fundamental 
actions,  or  the  actions  which  are  carried  on  in  a  reflex  manner,  and  which 
are  in  great  measure  independent  of  the  cephalic  ganglia.  In  this  con- 
nection the  intercostal  muscles,  the  diaphragm,  abdominal  muscles,  and 
the  muscles  constituting  the  floor  of  the  pelvis  will  immediately  suggest 
themselves.  In  the  lower  extremity  the  most  general  movements  may 
be  expected  to  be  regulated  by  the  antero-lateral  group.  These  move- 
ments are  flexion  of  the  thigh  on  the  body,  of  the  leg  on  the  thigh,  and 
elevation  of  the  heel.  It  may  be  said  that  elevation  of  the  heel  is  a 
movement  almost  peculiar  to  man,  but  this  is  rendered  necessary  during 
locomotion,  owing  to  the  depression  of  the  heel  which  has  been  efi'ected 
in  the  course  of  evolution,  by  the  progressive  increase  in  the  strength  of 
the  flexors  of  the  foot  on  the  leg. 

On  watching  the  first  movements  of  the  human  infant  ifc  will  be  seen 
that  the  power  to  elevate  the  heel  is  acquired  early,  while  the  elevation  of 
the  toe  so  as  to  allow  the  foot  to  swing  forwards  by  its  own  weight  is  the 
last  movement  acquired  ;  hence  it  is  the  most  special  movement,  and  it  will 
be  represented  in  the  cord  by  the  superaddition  of  new  ganglion  cells  to 
those  already  existing.  What  the  movements  are  which  are  regulated  by 
means  of  the  antero-lateral  group  in  the  cervical  region  I  can  only  make 
a  rough  conjecture.  They  are  no  doubt  the  simplest  movements,  and 
those  which  man  possesses  in  common  with  the  lower  animals.  The  most 
probable  of ^  these  movements  are  flexion  at  the  wrist,  simple  flexion  and 
extension  at  the  elbow,  and  the  backwards  and  forwards  movements  at 
the  shoulder,  and  flexion  of  the  neck  and  head.  Some  of  the  muscles 
engaged  in  these  actions  we  have  already  found  reason  to  believe  were 
innervated  by  the  postero-lateral  group  ;  but  this  does  not  exclude  the 
possibility  of  their  being  innervated  also  by  the  antero-lateral  group. 
There  is  so  much  uncertainty,  however,  with  regard  to  the  function  of  the 


ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION.  75 

autero-lateral  group  in  the  cervical  region  that  it  would  be  hazardous 
to  make  any  assertion  with  regard  to  it.  There  is  also  quite  as  much 
uncertainty  with  respect  to  the  functions  of  the  central,  internal,  and 
anterior  groups. 

§  375.  Reflex  Action. — The  production  of  reflex  action  is  one 
of  the  earliest  and  most  fundamental  functions  of  the  spinal 
cord.  As  we  have  already  seen,  every  reflex  act  requires  for  its 
performance  an  afferent  and  an  efferent  fibre,  and  a  centre- 
The  earlier-formed  ganglion  cells  of  the  anterior  grey  horns  con- 
stitute the  centres  of  reflex  action;  and  it  is  probable  that  the 
reflex  afferent  fibres  pass  to  them  directly,  without  the  inter- 
vention of  the  grey  substance  of  the  posterior  horns.  Inasmuch 
as  the  reflex  afferent  fibres  are  formed  at  an  early  period  in  the 
development  of  the  cord,  they  must  be  thrust  out  laterally 
during  the  development  of  the  posterior  grey  horn,  so  that 
they  will  occupy  an  external  position  in  the  fan  formed  by 
the  spreading  out  of  the  fibres  of  the  posterior  roots.  We 
have  already  seen  that  there  are  grounds  for  believing  that  the 
afferent  fibres  of  the  tendinous  reflexes  pass  in  the  inner  radi- 
cular fasciculus,  and  it  is  not  improbable  that  the  afferent 
fibres  of  the  cutaneous  reflexes  pass  in  the  outer  radicular 
fasciculus.  The  efferent  reflex  fibres  pass  out  in  the  anterior 
roots,  and  the  same  fibres  probably  convey  both  reflex  and 
voluntary  impulses. 

§  376.  Trophic  Function  of  the  Cord. — It  is  well  known  that 
the  ganglion  cells  of  the  anterior  horns  of  the  cord  exercise  a 
trophic  influence  on  the  muscles  ;  but  whether  there  are  trophic 
cells  endowed  with  special  functions,  or  whether  all  the  cells 
are  endowed  with  both  motor  and  tropl^ic  functions,  I  am  unable 
to  say.  With  some  degree  of  qualification,  I  feel  inclined  to 
adopt  the  latter  view. 

It  is  well  known  that  within  certain  limits,  increased  func- 
tional activity  of  a  muscle  is  followed  by  an  increase  in  its 
bulk,  and,  conversely,  that  a  diminution  of  its  activity  is  followed 
by  diminution  of  its  bulk.  When,  therefore,  the  mechanism  in 
the  cord,  which  regulates  the  movements  of  the  muscle,  is  in  a 
state  of  activity,  this  is  followed  by  an  increase  in  the  function  of 
the  muscle,  and  consequently  by  an  increase  in  its  bulk.    If,  in 


76  ANATOMICAL   AND   PHYSIOLOGICAL  INTRODUCTION. 

addition  to  an  increase  in  its  bulk,  the  muscle  be  called  upon 
to  make  a  new  adjustment  in  response  to  altered  circumstances, 
the  new  adjustment  can  only  become  permanent  in  the  race 
when  it  is  organised  in  the  cord  by  the  growth  of  new  cells  and 
fibres  in  addition  to  the  original  mechanism  by  which  its  move- 
ments were  guided.  But  if  the  new  cells  and  fibres  become 
incapacitated  from  any  cause,  the  muscle  will  soon  lose  the 
structural  modification  which  corresponded  to  its  recently- 
acquired  functional  adjustment,  but  no  other  change  will  take 
place  in  it.  As  long  as  the  original  mechanism  is  maintained 
in  the  cord,  so  long  will  the  nutrition  of  the  great  bulk  of  the 
muscle  go  on  as  before.  But  tbe  case  is  very  different  when 
the  function  of  the  original  mechanism  is  destroyed  ;  then  the 
nutrition  of  the  muscle  is  injured  at  its  very  foundation,  and 
profound  trophic  changes  occur.  It  is  very  probable,  therefore, 
that  the  inflaence  exerted  by  the  later-developed  ganglion  cells 
of  the  anterior  horns  on  the  nutrition  of  the  muscles  is  small, 
while  that  of  the  earlier-developed  cells  is  very  great. 

§  377.  Automatic  Action. — The  spinal  cord  contains  a  con- 
siderable number  of  what  are  regarded  as  automatic  centres, 
but  it  is  probable  that  many  of  these  act  in  a  reflex  manner. 
The  lumbar  portion  of  the  cord  contains  centres  for  the 
regulation  of  the  acts  connected  with  micturition,  defecation, 
erection  and  ejaculation,  and  parturition.  The  oculo-pupillary 
centres  in  the  upper  dorsal  and  cervical  regions  of  the  cord  have 
already  been  described. 

Vaso-motor  centres  exist  in  the  cord  by  means  of  which  the 
tonus  of  tbe  muscular  coat  of  the  vessels  is  maintained.  It 
has  been  thought  that  the  spinal  cord  also  exercises  a  tonic 
action  over  the  skeletal  muscles,  but  this  opinion  is  doubtful. 
The  tone  of  the  sphincters  of  the  bladder  and  rectum,  however, 
is  undoubtedly  maintained  by  the  lumbar  part  of  the  cord, 
and  is  probably  reflex  in  character.  The  peristaltic  movements 
of  the  oesophagus,  stomach,  and  intestines  are  regulated  by  the 
central  grey  tube.  Little  is  known  beyond  conjecture  of  the 
localisation  of  the  centres  of  visceral  innervation  in  the  cord. 
That  they  are  not  situated  in  the  anterior  grey  horns  is  ren- 
dered certain  by  the  fact  that  the  visceral  movements,  and 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.  77 

the  automatic  actions  of  defecation,  micturition,  erection,  and 
parturition  remain  unaffected  in  disease  limited  to  the  anterior 
grey  horns. 

Several  considerations  may  be  adduced  tending  to  show  that 
the  vesicular  column  of  Clarke  contains  the  spinal  centres  of 
visceral  innervation.  The  cells  of  this  column  are  bipolar,  like 
those  of  the  sympathetic,  and  not  multipolar,  like  those  of  the 
anterior  horns  which  regulate  the  complicated  actions  of  the 
skeletal  muscles.  This  column  is  absent  in  the  lumbar  and 
cervical  enlargements,  the  portions  of  the  cord  which  supply 
nerves  to  the  limbs,  and  in  the  upper  half  of  the  cervical 
region  which  supplies  nerves  to  the  muscles  of  the  neck.  It 
is,  on  the  other  hand,  present  in  the  upper  lumbar  and  the 
dorsal  regions  of  the  cord — the  portions  from  which  the  trunk 
is  innervated,  and  is  again  represented  in  the  medulla  oblongata 
as  the  principal  nucleus  of  origin  of  the  vagus — the  most  im- 
portant visceral  nerve  of  the  body.  It  may  be  assumed  that  all 
the  actions  regulated  through  the  vesicular  colunin  of  Clarke 
are  subordinated  to  the  highest  expanded  portion  of  it  which 
constitutes  the  nucleus  of  the  vagus;  hence  there  is  no  reason 
to  assume  that  the  medulla  oblongata  contains  a  circumscribed 
vaso-motor  centre  distinctly  separated  from  the  nucleus  of  the 
vagus, 

§  378.  Functions  of  the  Posterior  Grey  Horns  and  Posterior 

Roots. 
Afferent  impulses  are  conducted  to  the  spinal  cord  by  the 
posterior  roots.  As  already  remarked,  it  is  probable  that  the 
afferent  impulses,  which  have  undergone  the  highest  organi- 
sation in  the  cord,  are  conducted  by  the  fibres  which  occupy  the 
periphery  of  the  fan,  formed  by  the  spreading  out  of  the  fibres 
of  the  posterior  roots  as  they  enter  the  substance  of  the  cord. 
In  the  anterior  horns  the  most  specialised  actions  are  repre- 
sented, partly  by  the  development  of  new  processes  to  the 
existing  ganglion  cells,  and  partly  by  the  growth  of  additional 
cells ;  but  in  the  posterior  horns  the  fibres,  which  conduct  the 
most  specialised  impulses,  have  become  adapted  to  their 
functions  by  the  gradual  development  in  connection  with  them 
of  special   peripheral  terminal  organs  on  the  one  hand,  and 


78  ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

central  terminal  organs  on  the  other.  The  stimulation  of 
certain  fibres  in  an  early  stage  of  development  may  give  rise 
only  to  diffused  and  irregular  contractions,  while  at  a  higher 
stage  of  development  complicated  and  apparently  purposive 
reflex  movements  are  produced  by  a  similar  stimulation;  again, 
a  stimulation  which  at  an  early  stage  of  development  gives 
rise  only  to  a  diffused  sensation  of  pain,  may  at  a  higher  stage 
of  development  evoke  intellectual  sensations  of  touch  and  tem- 
perature. It  may,  therefore,  be  expected  that  the  fibres  which 
conduct  reflex  impulses,  and  those  that  conduct  the  impulses 
which  on  reaching  the  cortex  of  the  brain  give  rise  to  the 
intellectual  sensations,  will  occupy  the  periphery  of  the  fan  of 
the  posterior  roots;  while  those  which  conduct  the  impulses 
which  on  reaching  the  cortex  give  origin  to  the  common  or 
emotional  sensations  will  occupy  its  centre.  We  have  already 
seen  reason  for  believing  that  the  afferent  fibres  of  the  tendinous 
reflexes  pass  through  the  internal  radicular  fasciculus  to  reach 
the  posterior  horn,  and  it  is  probable  that  the  afferent  fibres  of 
the  sense  of  touch  and  locality  also  pass  through  the  same  fasci- 
culus. We  have  also  supposed  that  the  cutaneous  reflex  fibres 
pass  through  the  external  radicular  fasciculus,  and  it  is  probable 
that  the  afferent  fibres  of  the  sense  of  temperature  likewise  pass 
through  this  bundle.  The  afferent  fibres  of  the  common  sensa- 
tion of  pain  pass  through  the  centre  of  the  posterior  roots 
directly  into  the  grey  matter  of  the  posterior  horns. 

Section  of  the  white  posterior  column  destroys  the  sensation 
of  touch  permanently  in  the  regions  situated  below  the 
section,  but  leaves  the  sensation  of  pain  unaff"ected ;  and,  con- 
versely, section  of  the  entire  grey  substance,  leaving  the  posterior 
columns  intact,  destroys  the  sense  of  pain  and  leaves  that  of 
touch  (Schifif). 

A  retardation  of  the  conduction  of  sensation  occurs  when  the 
posterior  grey  horns  are  cut,  and  the  more  the  grey  substance  is 
diminished  the  more  marked  is  the  retardation.  The  conduction 
of  sensory  impressions  decussates  in  the  cord  soon  after  the  root 
fibres  enter  it,  but  considerable  difference  of  opinion  exists  as  to 
the  mode  and  extent  of  this  decussation  with  regard  to  the  con- 
ducting paths  of  the  diflerent  kinds  of  sensation.  The  further 
course  of  the  afferent  fibres  through  the  cord  is  not  well  known. 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.  79 

It  is  supposed  that  the  sensory  paths  of  the  lower  extremities 
lie  at  first  in  the  lateral  columns,  and  do  not  enter  the  posterior 
columns  till  they  reach  a  higher  level.  The  posterior  column 
of  the  lumbar  region  is  said  to  contain  only  the  nerves  of  touch 
for  the  pelvic  region,  sexual  organs,  perinseum,  and  anal  region 
(Erb). 

§  379.  Fwndions  of  the  Central  Orey  Column. — The  central 
grey  column  is  not  supposed  to  be  endowed  with  any  active  func- 
tions, yet,  pathologically  regarded,  it  is,  as  will  hereafter 
appear,  one  of  the  most  important  portions  of  the  grey  sub- 
stance of  the  spinal  cord.  The  continuation  of  this  column  in 
the  medulla  oblongata  contains,  as  we  have  seen,  the  accessory 
nuclei ;  and  the  median  areas  of  the  anterior  horn  in  the  cervical 
and  lumbar  enlargements,  as  well  as  the  medio-lateral  areas 
in  the  dorsal  and  upper  cervical  regions,  may  be  regarded 
respectively  as  anterior  and  lateral  outgrowths  of  the  central 
column,  instead  of  being  regarded  as  portions  of  the  anterior 
horns.  These  areas,  indeed,  constitute  the  border-land  between 
the  central  column  and  anterior  horn,  and  they  are  involved 
in  the  diseases  of  both  structures. 

§  380.  Functions  of  the  Special  Nuclei  of  the  Medulla 
Oblongata,  Pons,  and  Crura. — The  functions  of  the  special 
nuclei  do  not  require  extended  consideration  at  present.  All 
of  them  serve  to  transmit  impulses  received  through  the  nerves 
of  special  sense,  not  only  to  the  cortex  of  the  brain,  but  probably 
also  to  the  cortex  of  the  cerebellum,  while  likewise  ministering 
to  complex  reflex  actions.  The  corpora  quadrigemina,  for  instance, 
are  anatomically  connected,  not  only  with  the  cerebrum,  but 
also  with  the  superior  peduncles  of  the  cerebellum ;  while  they 
have  been  proved,  both  anatomically  and  experimentally,  to 
form  an  important  reflex  centre  between  the  retina  and  the 
internal  and  external  muscles  of  the  eye.  It  is,  indeed,  likely 
that  still  more  extensive  and  complex  reflex  actions  are  regu- 
lated by  the  corpora  quadrigemina,  since  they  are  known  to  be 
anatomically  connected  with  the  upward  continuation  of  the 
anterior  root -zones  of  the  spinal  cord.  Two  of  the  four  nuclei 
of  origin  of  the  auditory  nerve  are  intimately  connected  with 


80  ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

the  inferior  and  middle  peduncles  of  the  cerebellum,  and  it  is 
probable  that  one  of  them  at  least  conducts  labyrinthine  im- 
pressions to  the  cerebellum. 

The  corpora  quadrigemina  are  homologous  with  the  optic  lobes  in  fishes 
and  the  lower  vertebrata — organs  which  are  developed  in  connection  with 
the  sense  of  sight.  These  ganglia  appear  to  be  the  centres  for  the  reflex 
co-ordination  of  all  the  muscular  actions  concerned  in  the  movements  of 
the  eyeballs  and  of  the  refles  contraction  of  the  pupils  caused  by  light 
falling  on  the  retinse.  It  is  through  these  bodies,  and  not  directly,  that 
the  optic  tracts  come  into  relation  with  the  cerebellum  ;  hence  it  may  be 
expected  that  they  will  be  associated  with  the  latter  in  its  functions.  We 
have  already  seen  that  the  corpora  quadrigemina  are  connected  with  the 
anterior  root-zones,  or  the  system  of  fibres  which  co-ordinate  the  actions 
of  the  cord  longitudinally  on  the  side  of  the  outgoing  currents  ;  hence  the 
inferior  segments  of  the  body  are  to  a  considerable  extent  brought  under 
the  regulative  influence  of  these  ganglia.  The  corpora  quadrigemina  are, 
however,  simple  co-ordinating  centres,  and  their  regulative  action  on  the 
inferior  segments  of  the  body  is  of  a  purely  reflex  character.  The 
following  may  be  taken  as  an  illustration  of  the  manner  in  which  I 
believe  them  to  act : — While  a  fish  is  swimming  through  the  water 
a  sudden  impression  is  made  on  the  right  eye  by  the  shadow  of  a 
large  approaching  object,  and  immediately  the  muscles  of  the  tail  on 
the  left  side  contract,  and  the  head  is  turned  away  from  the  object. 
Such  a  movement  would  tend  to  secure  the  safety  of  the  fish  from 
capture  by  a  more  powerful  antagonist.  If,  on  the  other  hand,  the 
impression  is  made  by  a  relatively  small  object,  the  muscles  of  the  tail 
on  the  same  side  might  contract,  so  as  to  turn  the  head  towards 
the  object — a  movement  which  would  tend  to  secure  prey.  In  these 
movements  the  main  regulative  centres  are  the  optic  lobes,  and  there  is 
no  occasion  to  believe  that  the  actions  are  in  any  way  of  a  difierent 
character  from  the  ordinary  reflex  movements  of  the  spinal  cord.  It  may, 
however,  be  remarked,  in  passing,  that  since  a  large  approaching  object 
would  produce  a  greater  impression  than  a  small  object,  a  rudimentary 
eye  would  be  more  useful  to  its  possessor  for  avoiding  capture  than  in 
securing  prey ;  and,  consequently,  the  primary  and  fundamental  connection 
between  the  eye  and  the  inferior  segments  of  the  body  would  be  a  crossed 
one.  The  most  ready  communication,  therefore,  would  be  between  the 
right  eye  and  the  muscles  of  the  left  side  of  the  body.  And  this  helps  to 
explain  the  crossing  of  the  optic  nerves,  not  only  in  the  lower  animals  with 
rudimentary  eyes,  but  in  the  higher  organisms ;  since,  during  the  develop- 
ment of  the  latter  from  the  former,  the  primary  and  fundamental  crossing, 
however  much  it  may  be  modified,  is  still  retained.  It  is,  indeed,  very 
probable  that  the  crossed  connection  which  may  be  supposed  to  exist  in 
the  lower  vertebrata  between  the  rudimentary  eyes  and  the  muscles  of  the 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.  81 

body  was  the  main  factor  in  determining  during  the  course  of  development 
the  crossed  connection  which  exists  between  the  cerebral  hemispheres  and 
the  spinal  cord  in  the  higher  vertebrata. 

§  881.  Functions  of  the  Superadded  Grey  Substance  of  the 
Medulla  Oblongata,  Pons,  and  Crura. — We  have  already  seen 
that  there  are  no  grounds  for  believing  that  the  centres  of 
respiration,  deglutition,  mastication,  and  the  regulation  of  the 
heart's  action,  the  vaso-motor  diabetic,  and  so-called  con- 
vulsive centre  of  Nothnagel,  are  represented  by  grey  matter 
in  the  medulla,  apart  from  that  which  is  the  up'ward  con- 
tinuation of  the  grey  substance  of  the  spinal  cord,  and  conse- 
quently the  masses  of  grey  matter  which  are  superadded  in  the 
medulla,  pons,  and  crura,  must  preside  over  other  important 
functions.  Little,  however,  is  known  with  respect  to  these.  The 
most  reasonable  supposition  I  can  form  is  that  all  of  them  are 
coDnected  with  the  cerebello-spinal  system,  and  are,  therefore, 
engaged  in  regulating  the  tonic  muscular  contractions  rendered 
necessary  to  maintain  the  various  attitudes  of  the  body. 

§  382.  Functions  of  the  White  Substance. — According  to  the 
fundamental  law  of  development  already  mentioned,  we  may 
expect  that  the  parts  of  the  cord  which  begin  to  develop  at  an 
early  period  are  engaged  in  the  most  general  actions ;  while 
those  which  develop  at  a  late  period  are  engaged  in  the  most 
special  actions.  The  most  general  actions  of  the  cord  are  those 
which  it  performs  as  a  group  of  simple  co-ordinating  centres; 
and  the  most  special  are  those  which  it  performs  in  subordina- 
tion to  the  compound  and  doubly  compound  co-ordinating 
centres.  We  may,  therefore,  expect  to  find  that  the  anterior 
and  posterior  root-zones,  which  appear  at  a  comparatively  early 
period  in  the  development  of  the  cord,  belong  to  the  spinal 
system  of  simple  co-ordinating  centres,  while  the  direct  cere- 
bellar fibres,  the  column  of  Goll,  and  the  pyramidal  tract,  which 
appear  at  a  comparatively  late  period  of  development,  bring  the 
simple  co-ordinating  centres  of  the  cord  under  the  control  and 
guidance  of  the  compound  and  doubly  compound  co-ordinating 
encephalic  centres.  So  far  as  can  be  ascertained,  this  expectation 
is  realised. 

G 


82         ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

§  383.  Functions  of  the  Anterior  and  Posterior  Root-zones. 
These  consist,  as  already  stated,  of  looped  fibres,  which  connect 
ganglion  cells  at  different  elevations  in  the  cord.  The  anterior 
root-zone  maintains  a  close  relationship  with  the  anterior  grey 
horns,  and  its  fibres  probably  assist  in  co-ordinating  efferent 
impulses  from  above  downwards.  But  although  the  anterior 
root- zone  belongs  primarily  to  the  spinal  system,  it  is  not  im- 
probable that  it  may  have  become  at  a  subsequent  stage  of 
development  connected  indirectly,  if  not  directly,  with  some 
of  the  cephalic  centres.  The  close  relationship  of  the  olivary 
body  with  the  anterior  root-zone  in  the  medulla  would  seem 
to  imply  that  the  latter  may  be  the  medium  of  conveying 
efferent  impulses  from  the  cerebellum.  The  anterior  root-zone 
is  also  probably  connected  with  the  corpus  striatum,  and  may 
therefore  be  the  channel  through  which  the  efferent  impulses 
from  the  latter  are  conveyed  downwards  to  the  cord.  It  is  also 
connected  with  the  corpora  quadrigemina,  and  may  serve  to 
convey  reflex  impulses  originating  in  the  retina  down  the  cord. 
The  posterior  root-zone,  on  the  other  hand,  maintains  an  equally 
close  relationship  with  the  posterior  grey  horns,  and  its  fibres 
probably  assist  in  co-ordinating  afferent  impulses  from  below 
upwards.  We  have  seen  that,  with  the  exception  of  the  part 
which  belongs  to  the  sensory  roots  of  the  fifth  nerve  and  the 
fasciculus  rotundus,  the  posterior  root-zone  terminates  in  the 
triangular  nucleus,  and  that  the  latter  is  connected  by  arcuate 
fibres  with  the  olivary  body,  which  in  its  turn  is  connected 
with  the  opposite  half  of  the  cerebellum.  This  indirect  con- 
nection with  the  cerebellum  would  appear  to  indicate  that 
some  at  least  of  the  fibres  of  the  anterior  root-zone  belong  to 
the  cerebello-spinal  system. 

§  384,  Functions  of  the  Direct  Cerebellar  Tract. — This  tract 
belongs  to  the  cerebello-spinal  system,  its  fibres  connecting  the 
vesicular  column  of  Clarke  and  the  cortex  of  the  cerebellum 
(Flechsig),  Little  is  known  with  regard  to  the  functions  of 
these  fibres,  except  that  they  appear  to  convey  afferent  im- 
pulses. This  is  presumed  to  be  the  case,  because  when  the 
fibres  of  the  tract  are  injured  in  any  part  of  their  course,  the 
portions  above  the  seat  of  injury  undergo  rapid  degeneration. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTKODUCTION.  83 

§  385.  Functions  of  the  Column  of  Ooll. — This  column  must 
be  regarded  as  a  special  structure  from  the  comparatively  late 
period  at  which  it  is  developed.  Its  fibres  also  undergo  rapid 
degeneration  above  the  seat  of  injury;  hence  it  may  be  inferred 
that  they  convey  afferent  impulses,  but  nothing  further  is  known 
with  regard  to  their  functions. 

§  386.  Functions  of  the  Pyramidal  Tract — This  tract  is  now 
well  known  to  be  the  means  of  communication  between  the 
motor  area  of  the  brain  and  the  anterior  grey  horns  of  the  cord. 

The  fibres  which  pass  into  the  lateral  column  connect  the 
anterior  grey  horn  of  one  side  with  the  cortex  of  the  opposite 
side ;  while  those  which  constitute  the  column  of  Tiirck  connect 
the  anterior  horns  and  cortex  on  the  same  side.  When  the 
fibres  of  the  tract  are  injured  in  any  part  of  their  course  the 
portions  below  the  seat  of  injury  undergo  rapid  degeneration, 
and  this  fact  alone  is  sufficient  to  indicate  that  these  fibres 
convey  efferent  impulses.  This  tract  is,  indeed,  the  channel  by 
means  of  which  voluntary  impulses  are  conveyed  from  the  cortex 
of  the  brain  to  the  spinal  cord.  The  crossed  and  direct  connec- 
tion which  this  tract  forms  between  the  cortex  of  the  brain  and 
the  grey  anterior  horns,  is  rendered  necessary  by  the  fact  that 
every  movement  of  one  side  of  the  body  alters  the  centre  of 
gravity,  and  necessitates  a  new  adjustment  of  the  opposite  side. 
I  obtained  this  idea  in  a  conversation  with  Dr.  Hughlings 
Jackson,  and  he  illustrated  his  meaning  by  showing  that  when 
a  man  stands  on  the  ball  of  the  right  foot,  and  stretches  his 
right  arm  upwards  and  forwards  to  reach  an  object,  the  body 
being  also  inclined  forwards,  the  left  leg  is  instinctively  thrust 
backwards,  and  the  left  arm  downwards  and  backwards,  in  order 
to  keep  the  centre  of  gravity  as  far  back  as  possible  and  so  to 
prevent  the  line  of  gravity  from  passing  in  front  of  the  ball  of 
the  right  foot.  The  muscular  contractions  of  the  right  side  of  the 
body  may  be  supposed  to  be  regulated  in  this  action  from  the  left 
cortex  of  the  brain  through  the  fibres  of  the  pyramidal  tract  of 
the  lateral  column  of  the  right  side,  while  the  movements  of 
the  left  arm  and  leg  are  also  regulated  from  the  left  cortex,  but 
the  impulses  are  conveyed  to  the  same  side  of  the  cord  and  of 
the  body  by  the  fibres  of  the  column  of  Tiirck. 


84 


CHAPTER   II. 


MORBID  ANATOMY  AND  CLASSIFICATION  OF  THE 
DISEASES  OF  THE  SPINAL  CORD  AND  MEDULLA 
OBLONGATA. 


.      (I.)— MORBID  ANATOMY  OF  THE  SPINAL  COED  AND 
MEDULLA  OBLONGATA. 

In  the  preceding  chapter  we  have  traced  the  operation  of  the 
law  of  evolution  in  the  development  of  the  spinal  cord  and 
medulla  oblongata ;  we  must  now  trace  the  operation  of  the 
law  of  dissolution  in  the  breaking  down  of  the  structure  of 
these  organs  by  disease. 

§  387.  Histological  Changes.  —  The  histological  changes 
which  occur  in  the  various  elements  of  the  structure  of  the  cord 
must  first  be  briefly  described. 

1.  Morbid  Changes  of  the  Ganglion  Cells. 

(a)  Hypertrophy. — In  acute  inflammation  of  the  cord  the  ganglion  cells 
become  swollen,  their  contents  clondy  and  granular,  the  processes  also 
taking  part  in  the  changes  {Fig.  144,  2).  These  cells  often -contain  a 
large  amount  of  yellow  pigment,  a  condition  which  has  been  described 
by  Dr.  AUbutt  as  "  yellow  degeneration  "  {Ficj.  144,  3). 

(6)  Shrinking. —  In  the  acute  diseases  of  the  grey  substance  of  the 
cord,  the  ganglion  cells,  especially  the  small  cells  of  the  median  areas, 
become  shrivelled,  their  fluid  contents  appear  to  have  escaped,  and  the 
cell  wall  to  have  shrunk  around  the  nucleus  and  a  small  quantity  of 
yellow  pigment  {Fig.  144,  4).  At  a  subsequent  period  the  cells  lose  their 
processes  and  become  converted  into  small  angular  masses,  in  which 
even  a  nucleus  cannot  be  detected. 

(c)  Multiplication  of  the  Nucleus  and  Nucleolus. — The  nucleus  and 
nucleolus  may  at  times  be  observed  either  to  have  divided  into  two,  or 
to  exhibit  an  hour-glass  contraction  indicating  that  the  process  of  division 
has  commenced. 

(d)  Vacuolation.  —  Two  or  three  large  spherical  air  spaces,  named 


MORBID  ANATOMY   OF   THE   SPINAL   CORD. 


85 


vacuoles,  may  sometimes  be  observed  in  ganglion  cells  which  have  under- 
gone a  granular  degeneration  {Fig.  144,  7). 

(e)  Colloid  Degeneratio7i. — The  hypertrophied  cells  of  the  early  stage 
of  inflammation  may  subsequently  undergo  colloid  degeneration.  Their 
processes  become  transparent,  glistening,  brittle,  and  a  large  number  of 
them  are  broken  off  so  that  the  cells  assume  a  rounded  form.  The  cell 
wall  has  a  glassy  appearance,  and  assumes  brilliant  tints  when  stained  by 
various  aniline  dyes.  The  colloid  appearances  may  probably  be  the  result 
of  post-mortem  changes,  and  consequently  considerable  caution  must  be 
exercised  in  accepting  them  as  evidences  of  disease. 

{f)  Pigmentary  Degeneration. — The  best  examples  of  pigmentary  de- 
generation are  seen  in  the  chronic  diseases  of  the  cord.    The  cell  wall 

Fig.  ]44. 


Fig.  144  (Young).  Ganglion  Cells  of  the  Anterior  Grey  Horns  of  the  Spinal  Cord.  - 
1,  Healthy  caudate  cell;  2,  Hypertrophied  cell;  3,  Yellow  degeneration  (the 
yellow  colour  cannot  be  represented  here) ;  4,  Shrivelled  cell ;  5,  Chronic 
atrophy,  a  group  of  cells  from  a  case  of  pseudo-hypertrophic  paralysis  ;  6,  Pig- 
mentary atrophy  ;  7,  Vacuolation,  from  a  case  of  canine  chorea  (Gowers) ; 
8,  Chronic  atrophy,  from  a  case  of  progressive  muscular  atrophy- -"  yellow 
atrophy." 


86  MORBID  ANATOMY  OF  THE 

becomes  contracted  around  a  mass  of  dark  granular  pigment,  the  nucleus 
and  nucleolus  are  indistinct  or  obliterated,  the  processes  are  atrophied, 
and  many  of  them  have  disappeared  {Fig.  144,  6). 

{g)  Atrophy.  —  In  chronic  diseases  the  cell  wall  becomes  dense  and 
contracted,  the  processes  broken  ofif,  and  the  remnant  of  the  cell  converted 
into  a  small  angular  mass,  without  recognisable  nucleus  or  nucleolus,  and 
finally  all  traces  of  the  cell  may  be  lost  {Fig.  144,  5  and  8). 

(Ji)  Calcareous  degeneration  of  the  ganglion  cells  of  the  cord  is  rarely 
observed  (Forster). 

2,  Morbid  Changes  of  the  Nerve  Fibres. 

The  meduUated  nerve  fibres  of  the  spinal  cord  undergo  alterations 
more  or  less  similar  to  those  which  have  already  been  described  in  the 
case  of  the  fibres  of  the  peripheral  nerves,  and  consequently  these  changes 
need  not  be  described  here  in  detail. 

{a)  Hypertrophy  of  the  Axis  Cylinder, — In  myelitis  it  is  not  rare  to 
observe  on  transverse  section  that  the  axis  cylinders  of  many  of  the  fibres 
have  increased  to  two  or  three  times  their  normal  dimension.  In  longitu- 
dinal sections  it  is  seen  that  the  swelling  does  not  extend  the  whole  length 
of  the  axis  cylinder ;  the  latter  presents  a  varicose  appearance,  so  that 
its  diameter  is  much  diminished  in  size  at  some  points. 

(6)  Atrophy  of  the  nerve  fibres,  similar  to  that  which  occurs  in  the  peri- 
pheral nerves  when  the  fibres  are  severed  from  their  trophic  centres,  may 
be  observed  in  the  meduUated  fibres  of  the  spinal  cord.  This  atrophy 
begins  by  coagulation  of  the  myeline,  which  becomes  granular  and  broken 
up  into  globular  masses  that  are  finally  absorbed.  The  axis  cylinder  per- 
sists for  a  long  time  after  the  medullary  sheath  has  disappeared,  but  by- 
and-by  it  also  diminishes  in  size,  and  ultimately  disappears. 

(c)  Calcareous  degeneration  of  the  fibres  of  the  cord  has  been  excep- 
tionally observed  (Forster,  Virchow). 

3.  Morbid  Changes  of  the  Neuroglia  and  Connective  Tissue. 

(a)  Gliige's  corpuscles  consist  of  large  globular  cells  filled  with  granular 
contents.  These  cells  may  be  observed  in  the  spinal  cord  of  the  embryo, 
but  are  never  met  with  in  considerable  numbers  in  the  cord  of  the  adult, 
except  in  cases  of  disease.  They  are  supposed  to  derive  their  origin  from 
fatty  degeneration  of  the  cells  of  the  connective  tissue  and  neuroglia,  the 
white  corpuscles  of  the  blood,  and  the  endothelial  cells  of  the  vessels  and 
of  the  capsules  of  the  ganglion  cells. 

(6)  Amyloid  Corpuscles  and  Colloid  Bodies. — Amyloid  corpuscles  (cor- 
pora amylacea)  are  small,  round,  concentrically  laminated  bodies.  Most  of 
them  are  turned  blue,  or  bluish  grey,  when  acted  on  by  iodine  alone,  and 
assume  a  beautiful  bright  blue  tint  on  the  addition  of  sulphuric  acid. 
Colloid  bodies  are  irregular  masses,  consisting  apparently  of  changed 
myeline ;  they  assume  beautiful  tints  on  being  stained  with  logwood,  or 
some  of  the  aniline  dyes.    It  is  probable  that  these  bodies  may  be  the 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  87 

result  of  post-mortem  decomposition,  and  neither  they  nor  the  amyloid 
corpuscles  afford  trustworthy  evidences  of  disease. 

(c)  Deiter's  cells  appear  to  be  increased  in  number  in  inflammatory 
diseases  of  the  cord. 

(d)  Hypertrophy  and  Hyperplasia  of  the  Connective  Tissue. — The  septa 
of  connective  tissue  become  swollen,  and  the  nuclei  of  the  neuroglia 
largely  increased  in  number.  It  is  also  probable  that  leucocytes,  which 
have  migrated  from  the  vessels  during  inflammatory  processes,  may  sub- 
sequently become  organised,  and  thus  increase  the  normal  volume  of  the 
connective  tissue  of  the  cord. 

(c)  Sclerosis  and  Retraction. — When  hyperplasia  of  the  connective 
tissues  has  once  taken  place,  the  newly-formed  tissue  may  subsequently 
undergo  cicatricial  contraction,  and  thus  lead  to  the  destruction  of  the 
nervous  elements.  The  process  which  leads  to  sclerosis  often  begins  in 
the  nerve  cells  and  fibres,  and  may  be  called  parenchymatous  sclerosis.  At 
other  times  the  morbid  changes  appear  to  begin  in  the  connective  tissue 
or  neuroglia,  the  nerve  cells  and  fibres  being  secondarily  invaded  ;  this 
form  may  be  called  interstitial  sclerosis. 

4.  Morbid  Alterations  of  the  Vessels. 

(a)  Intravascular  Changes. — The  vessels  are  at  times  greatly  distended 
with  blood,  but  this  is  not  a  trustworthy  evidence  of  disease,  inasmuch  as 
the  distension  may  have  occurred  from  the  mode  of  dying,  or  from  hypo- 
static congestion  after  death.  The  capillary  arteries  may  at  times  be 
distended  with  emboli. 

(b)  Changes  in  the  walls  of  the  spinal  vessels  are  observed  in  chronic 
Bright's  disease,  identical  with  those  which  occur  in  the  vessels  of  the 
body  generally  in  that  disease. 

(c)  Perivascular  Changes. — The  most  important  perivascular  changes 
observed  in  disease  of  the  spinal  cord  are  caused  by  migration  of  the  white 
corpuscles  of  the  blood  into  the  perivascular  lymph-spaces  and  surround- 
ing tissues.  The  number  of  leucocytes  surrounding  a  vessel  may  some- 
times be  so  great  as  to  constitute  what  has  been  called  a  miliary  abscess 
(Plate  v.,  Fig.  2).  Rupture  of  a  vessel  may  occur,  giving  rise  to 
haemorrhage  into  the  tissues.  Red  blood  corpuscles  are  at  times  localised 
in  a  perivascular  space,  but  it  is  difiicult  to  determine  in  these  cases 
whether  the  red  corpuscles  have  escaped  by  rupture,  or  have,  like  the  white 
corpuscles,  migrated  through  the  wall  of  the  vessel. 

§  388.  Let  us  now  pass  from  the  details  of  the  morbid  changes 
of  the  cord  to  the  general  principles  which  underlie  them.  In 
accordance  with  the  law  of  dissolution  (§  35)  we  may  expect 
that  the  accessory  portions  of  the  cord  will  form  parts  of  least 
resistance  to  the  inroads  of  disease. 

In  the  grey  substance  the  least  resistance  to  disease  will  be 


88  MORBID  ANATOMY   OF   THE 

offered  by  the  central  column,  which  is,  as  we  have  already 
seen,  the  embryonic  area  of  the  cord,  and  by  the  median  area 
of  the  anterior  grey  horn  in  the  lumbar  and  cervical  enlarge- 
ments and  the  medio-lateral  area  in  the  dorsal  and  upper 
cervical  regions — areas  which,  as  already  remarked,  may  be 
regarded  as  outgrowths  of  the  central  column.  These  areas 
contain  the  accessory  nuclei  of  the  spinal  cord,  and  since  these 
ganglion  cells  not  only  are  developed  at  a  comparatively  late 
period,  but  also  frequently  maintain  a  relatively  small  size  in 
the  adult,  the  resistance  offered  to  the  invasion  of  disease 
becomes  still  less.  This  law  must  necessarily  be  true  whether 
the  disease  begin  in  the  ganglion  cells  themselves,  in  the 
neuroglia,  or  in  the  vessels,  or  whether  it  be  caused  by  a  poison 
circulating  in  the  blood,  provided  that  the  poison  possess  no 
special  affinity  for  any  one  set  of  the  ganglion  cells  more  than 
for  others. 

The  cell  walls  of  the  small  and  recently-developed  cells  are 
much  thinner  than  those  of  the  larger  and  earlier-developed 
cells,  hence  the  exchange  of  materials,  which  is  the  necessary 
accompaniment  of  nutrition,  takes  place  more  readily  in  the 
former  than  in  the  latter.  But  this  is  not  all.  A  large  cell 
presents,  in  proportion  to  its  bulk,  a  smaller  surface  to  its 
environment  for  the  absorption  of  nourishment  than  a  small 
cell,  and  consequently  the  relative  amount  of  nourishment 
absorbed  by  the  large  will  be  less  than  that  absorbed  by  the 
small  cell  (§  9).  But  high  nutritive  activity  is  associated  with 
great  instability,  which  declares  itself  in  increased  readiness  to 
give  out  energy  or  to  multiply,  the  latter  process,  of  course, 
involving  the  disorganisation  of  a  highly-organised  tissue. 

When,  therefore,  the  ganglion  cells  of  the  anterior  horns 
become  diseased,  it  may  be  expected  that  the  later-developed 
and  small  cells  will  be  the  first  to  suffer,  and  when  a  poison 
like  strychnine  circulates  in  the  blood,  the  same  cells  will  also 
be  the  first  to  be  affected,  supposing  the  drug  not  to  possess  a 
special  affinity  for  one  ganglion  cell  more  than  for  another. 
The  reason  of  this  is,  that  the  quantity  of  the  poison  which 
will  enter  the  substance  of  the  small  cell  will  be  much  larger 
in  proportion  to  its  bulk  than  that  which  will  enter  into  the 
substance  of  the  large  cell.     If  the  disease  begin  in  the  neu- 


SPINAL   CORD   AND   MEDULLA   OBLONGATA. 


89' 


Fig.  145. 


roglia,  it  may  be  expected  that  the  spongy  and  loose  neuroglia 
of  the  later-developed  portions  of  the  grey  substance  will  resist 
its  inroads  less  effectually  than  the  dense  neuroglia  surrounding 
the  earlier-developed  groups  of  ganglion  cells.  The  central 
grey  column  possesses  a  loose  and  spongy  neuroglia,  and  we 
have  seen  that  it  may  be  regarded  as  the  embryonic  area  of 
the  spinal  cord,  so  that  it  may  be  expected  to  offer  little 
resistance  to  the  invasion  of  disease.  We  shall  hereafter  see 
that  some  of  the  most  rapidly  fatal  diseases  of  the  cord  appear 
to  ascend  in  the  central  grey  column.  It  has  been  pointed  out 
that  the  later-formed  cells  of  the  anterior  horns  grow  close  to 
the  arteries,  while  the  earlier-developed  cells  are  pushed,  in  the 
course  of  development,  away  from  them.  When,  therefore, 
rapid  exudation  takes  place  from  the  vessels,  whether  it  consist 
of  a  fluid  and  granular  exudation 
or  of  migration  of  white  blood 
corpuscles,  the  cells  in  the  neigh- 
bourhood of  these  vessels  Avill 
suffer  sooner  and  in  greater  de- 
gree than  those  more  remote. 

That  the  lines  of  least  resis- 
tance to  disease  in  the  lumbar 
region  are  in  the  direction  of  the 
vessels  is  well  illustrated  by  Fig. 
145,  which  is  taken  from  a  section 
of  the  middle^  of  the  lumbar  en- 
largement in  a  case  of  infantile 
paralysis,  under  the  care  of  Dr. 
Humphreys,  at  the  Pendlebury 
Hospital  for  Sick  Children.  This 
case  is  described  in  the  "  Transac- 
tions of  the  Pathological  Society 
of  London"  for  1879,  and  will 
be  subsequently  mentioned.  My 
present  object  is  to  show  that 
even  in  an  acute  disease  like 
infantile  paralysis  the  cells  near 
the  vessels  have  become  de- 
stroyed   in    preference    to    the 


Fig.  145  (Young).  Section  of  the  Lum- 
bar Region  of  the  Spinal  Cord  from 
a  case  of  infantile  spinal  2^araly sis. 
pi,  postero- lateral  group;  al, 
antero-lateral  group ;  c,  central 
group.  The  internal  and  anterior 
groups  have  disappeared,  and  the 
marginal  cells  of  the  remaining 
groups  are  also  destroyed. 


90  MORBID  ANATOMY   OF  THE 

others.  If  Fig.  145  be  compared  with  Fig.  Ill,  it  will  be  seen 
at  once  that  the  disease  is  most  marked  in  the  vascular 
areas  of  the  cord,  and  that  the  cells  which  have  been 
last  developed  are,  on  the  whole,  those  which  have  suffered 
most  will  be  apparent  by  referring  to  the  previous  description 
and  illustrations  of  the  development  of  the  cord.  It  is  true 
that  the  earlier-developed  cells  of  the  internal  and  anterior 
groups  have  disappeared ;  but  the  cells  of  the  antero-lateral, 
and  those  of  the  central  portions  of  the  postero-lateral  and  of 
the  central  group  are  well  preserved ;  while  the  marginal  cells 
of  the  two  latter  groups  and  all  the  cells  of  the  median  area 
are  completely  destroyed.  It  is  not  likely  that  this  law  will 
always  be  observed  in  a  disease  having  such  an  acute  and 
sudden  onset  as  infantile  paralysis  ;  but  an  examination  of  the 
diagrams  given  by  Clarke,  Charcot,  and  Jofifroy,  shows  so  many 
indications  of  the  fulfilment  of  this  law  that  its  occurrence 
cannot  be  regarded  as  accidental.  The  same  law  is  observed, 
at  least  very  frequently,  in  cases  of  acute  and  subacute  ascend- 
ing central  myelitis,  as  well  as  in  tetanus  and  hydrophobia.  It 
was  while  examining  cases  of  this  kind  that  my  attention  was 
first  directed  to  this  subject.  In  all  the  acute  diseases  affecting 
the  grey  substance  of  the  spinal  cord  I  observed  that,  unless 
the  destruction  was  so  great  as  to  involve  the  anterior  horns 
in  their  entire  extent,  the  small  cells  and  those  in  the  line  of 
the  distribution  of  the  arteries  manifested  evidences  of  disease 
to  a  much  greater  extent  than  the  large  cells  and  those  removed 
from  the  vessels. 

The  distribution  of  the  disease  in  the  cervical  enlargement 
is  similar  to  that  in  the  lumbar  region,  except  that  the  median 
area  being  much  larger  in  the  former  than  in  the  latter,  injury 
to  this  area  forms  a  more  conspicuous  feature  of  disease  in  the 
former  than  the  latter.  When  the  dorsal  region  of  the  cord 
is  affected  by  acute  disease  of  the  grey  substance,  the  most 
marked  morbid  changes  are  observed  in  the  postero-lateral 
or  rather  the  medio-lateral  group;  and  the  same  is  the  case  in 
the  upper  cervical  region.  A  section  of  the  middle  of  the  cer- 
vical enlargement  is  represented  in  Fig.  146,  taken  from  a  case 
of  subacute  ascending  spinal  paralysis.  The  disease  began  after 
exposure  to  severe  cold  with  sudden  paralysis  of  the  lower 


SPINAL   CORD  AND  MEDULLA  OBLONGATA. 


91 


extremities,  without  much  disturbance  of  sensibility.  This  was 
followed  by  rapid  wasting  of  the  muscles,  and  loss  of  faradic 
contractility.  The  paralysis  in  the  course  of  a  few  weeks 
gradually  invaded  the  muscles  of  the  trunk,  the  muscles  of  the 
upper  extremity,  and  ultimately  the  muscles  of  respiration. 
Death  took  place  five  weeks  from  the  commencement  of  the 
paralysis.  In  the  lumbar  region  the  white  as  well  as  the  grey 
substance  was  implicated,  and  there  was  ascending  sclerosis  of 
both  the  columns  of  Goll  and  of  the  direct  cerebellar  tracts 
throughout  the  entire  length  of  the  cord ;  the  remaining  por- 
tions of  the  white  substance  were  healthy  in  the  dorsal  and 
cervical  regions.  The  central  grey  column  was  diseased 
throughout  the  whole  length  of  the  cord,  the  cells  of  the 
postero-lateral  group  and  medio -lateral  area  having  entirely 
disappeared  in  the  dorsal  region,  and  again  in  the  upper 
cervical  regions;  while  the  anterior  groups  of  cells  appeared 


Fig.  146. 


Fig.  146  (Young).  Section  of  the  Middle  of  the  Cervical  Enlargement  of  the  Spinal 
Cord  from  a  case  of  central  myelitis. — i.  The  internal  group  ;  the  remaining  letters 
indicate  the  same  as  the  corresponding  ones  in  Fig.  145.  The  median  area  was 
completely  destitute  of  cells,  and  a  large  number  of  the  marginal  cells  of  the 
different  groups  of  the  anterior  horn  were  destroyed  or  diseased. 


92  MORBID  ANATOMY  OF  THE 

to  be  quite  normal.  In  the  cervical  enlargement  {Fig,  146) 
the  cells  of  the  median  area  had  entirely  disappeared,  and  the 
marginal  cells  of  the  central  and  postero-lateral  groups  were 
notably  altered,  while  the  fundamental  cells  of  the  groups 
presented  beautiful  long  processes,  and  appeared  in  every 
respect  normal. 

§  389.  In  the  white  substance  the  last  developed  fibres  will 
also,  other  things  being  equal,  offer  less  resistance  to  the  inroads 
of  disease  than  the  earlier-developed  fibres.  In  proceeding  to 
verify  this  statement,  we  must  compare  the  later  with  the  earlier- 
formed  fibres  of  the  same  segment,  or,  in  other  words,  the  same 
functional  system  of  the  white  substance,  otherwise  the  whole 
result  will  be  vitiated.  The  posterior  and  anterior  root-zones, 
for  instance,  are  developed  about  the  same  time,  yet  the 
former  is  more  liable  to  become  diseased  than  the  latter. 
The  posterior  is  probably  more  exposed  to  the  exciting  causes 
of  disease,  such  as  peripheral  injuries  and  ascending  neuritis, 
than  the  anterior  root-zone,  and  the  small  fibres  of  the  former 
are  more  apt  to  be  injured  in  inflammatory  affections  of  the 
cord  than  the  larger  fibres  of  the  latter.  But  if  the  accessory 
be  compared  with  the  fundamental  fibres  of  the  pyramidal 
tract,  it  will  be  seen  that  the  former  are  much  more  exposed  to 
injurious  influences  than  the  latter.  The  small  diameter  of 
the  greater  number  of  the  accessory  fibres  permits  a  relatively 
larger  amount  of  nourishment  to  gain  access  to  their  interior 
than  can  take  place  in  fibres  of  larger  diameter ;  hence  both 
reparative  and  destructive  changes  are  more  rapidly  effected  in 
the  former  than  in  the  latter. 

The  accessory  fibres  are,  as  we  have  seen,  more  closely  related 
to  the  connective  tissue  septa  of  the  cord  than  the  fundamental 
fibres,  hence  the  former  are  more  liable  to  be  injured  in  the 
course  of  the  diseases  which  begin  in  the  connective  tissue  and 
neuroglia  than  the  latter.  An  appearance  which  is  presented  by 
the  spinal  cord  in  various  diseases,  and  which  for  a  long  time 
puzzled  me  very  much,  is  that  which  has  been  described  as  miliary 
sclerosis  (Rutherford,  Kesteven).  This  condition  appears  to 
consist  of  a  swelling  or  thickening  of  the  septa  in  which  the 
blood-vessels  run.     In  the  lozenge-shaped  spaces  {Fig.  133)  of 


SPINAL   CORD   AND  MEDULLA  OBLONGATA.  93 

the  pyramidal  tract  a  considerable  number  of  the  small 
fibres  which  lie  close  to  the  vessels  are  destroyed,  while  the 
larger  central  fibres  remain  more  or  less  healthy.  When  a 
transverse  section  of  the  cord  is  examined  under  these  circum- 
stances the  part  presents  a  spotted  appearance,  but  instead  of 
the  miliary  spots  being  in  a  state  of  sclerosis,  they  really  are 
the  most  healthy  portions  of  the  section.  The  proximity  of 
the  fibres  of  the  accessory  system  to  the  blood-vessels  renders 
them  also  more  liable  than  the  fundamental  fibres  to  be  injured 
by  inflammatory  and  other  effusions. 

§  390.  Secondary  Degenerations. 
The  medullated  fibres  of  the  spinal  cord  undergo  degene- 
ration whenever  their  continuity  is  interrupted.  The  short 
looped  fibres  of  the  anterior  and  posterior  root-zones,  however, 
only  degenerate  in  the  neighbourhood  of  the  lesion,  probably 
because  they  soon  terminate  in  grey  matter.  But  the  fibres 
which  pass  from  one  end  of  the  cord  to  another  are  sometimes 
found  degenerated  throughout  their  whole  length.  As  a  rule, 
however,  a  focal  lesion  interrupts  the  continuity  of  the  long 
fibres  in  some  part  of  their  course,  and  the  fibres  either  above 
or  below  the  seat  of  disease  undergo  degeneration.  Some 
pathologists  think  that  an  irritative  change  spreads  from  th6 
primary  lesion  as  a  centre  along  these  fibres,  but  the  most 
reasonable  supposition  is  that  the  degeneration  is  analogous  to 
what  occurs  in  the  fibres  of  peripheral  nerves  after  they  have 
been  severed  from  their  trophic  centres.  The  trophic  centres 
of  the  fibres  of  the  columns  of  Goll  and  of  the  direct  cere- 
bellar tract  are  situated  at  their  inferior  extremities — the 
posterior  horn  containing  the  trophic  centres  of  the  former, 
and  the  vesicular  column  of  Clarke  possibly  that  of  the 
latter.  When,  therefore,  the  continuity  of  these  fibres  is  inter- 
rupted at  any  point,  the  portions  above  the  seat  of  the  lesion 
undergo  degeneration,  consequently  degeneration  of  these  fibres 
is  called  ascending  sclerosis.  But  the  trophic  centres  of  the 
fibres  of  the  pyramidal  tract  are  situated  at  their  superior 
extremities,  these  centres  being  probably  formed  by  the  large 
ganglion  cells  of  the  fourth  layer  of  the  cortex  of  the  brain. 
When  the  continuity  of  these  fibres   is   interrupted   at   any 


9i  MOEBID  ANATOMY  OF  THE 

point  of  their  course,  the  portions  below  the  seat  of  the  lesion 
undergo  degeneration,  consequently  this  form  is  called  descend- 
ing sclerosis.  The  time  occupied  by  the  degeneration  appears 
to  be  from  four  to  eight  weeks.  Schiefferdecker  found  in 
experiments  on  dogs  that  it  began  at  the  end  of  fourteen  days, 
was  well  marked  at  the  end  of  four  to  five  weeks,  but  changes 
in  the  connective  tissue  were  not  observed  until  the  eighth 
week.  Degeneration  of  the  fibres  of  the  spinal  cord  appears 
always  to  take  place  in  the  line  of  their  conduction.  When  a 
transverse  section  of  the  spinal  cord  is  examined  by  the  naked 
eye  the  degenerated  portion  usually  presents  a  grey  or  greyish 
discolouration,  but  in  recent  cases  the  cord  presents  no  abnormal 
appearances  until  it  is  hardened  in  chromic  acid  or  bichromate 
of  ammonia.  In  cases  of  long  standing  the  degenerated 
columns  may  be  atrophied  to  such  an  extent  that  the  sym- 
metry of  the  cord  becomes  altered. 

Microscopic  examination  shows  that  in  the  earlier  stages  the 
nerve  fibres  are  exclusively  affected.  The  medullary  sheaths 
undergo  fatty  degeneration  and  ultimately  disappear,  while 
there  is  a  considerable  development  of  granule  cells ;  the  axis- 
cylinders,  however,  persist  for  some  time  afterwards. 

In  the  later  stages  of  degeneration  the  nerve  fibres  disappear 
entirely,  the  neuroglia  is  increased  in  quantity,  and  changes 
into  a  dense  finely  fibrillated  tissue,  which  contains  numerous 
nuclei  and  spindle  cells. 

1.  History. — Secondary  atrophy,  extending  to  the  pons  and  pyramids 
of  the  medulla,  was  observed  in  disease  of  the  brain  by  Cruveilhier  and 
Rokitansky,  but  they  did  not  follow  it  to  the  spinal  cord.  Tiirck  made  a 
thorough  examination  of  the  secondary  degenerations  of  the  spinal  cord 
in  1851  and  1853,  and  their  histological  characters  were  investigated  in 
1863  by  Leyden.  Various  French  authors,  as  Charcot,  Cornil,  and  others, 
published  cases  in  which  these  degenerations  were  observed,  but  the  most 
exhaustive  work  on  the  pathology  of  the  affection  was  published  by 
Bouchard  in  1866.  Soon  afterwards  Westphal  showed  that  secondary 
degenerations  could  be  produced  experimentally  in  dogs,  and  this  was 
afterwards  confirmed  by  Vulpian. 

2.  Distribution  of  the  Degeneration. — The  observations  of  Charcot  and 
Pierret,  and  subsequently  of  Flechsig,  tend  to  show  that  these  secondary 
degenerations  of  the  spinal  cord  are  determined  by  the  order  of  its  deve- 
lopment.    The  development  of  the  functional  systems  of  the  white  sub- 


SPINAL   COED   AND   MEDULLA   OBLONGATA. 


95 


stance  of  the  cord  affords  a  good  illustration  of  the  law  of  evolution, 
while  the  secondary  degenerations  afford  an  almost  equally  good  illustra- 
tion of  the  law  of  dissolution.  The  distribution  of  these  degenerations, 
therefore,  may  be  readily  understood  by  reference  to  Figs,  134  to  140, 
which  illustrate  the  development  of  the  cord. 

(a)  Ascending  degeneration  takes  place  above  the  seat  of  the  lesion  in 
the  columns  of  Goll,  and  terminates  in  the  upper  end  of  the  medulla 
oblongata,  where  the  fibres  end  in  the  cuneate  nucleus.  The  direct 
cerebellar  fibres  also  undergo  ascending  degeneration.  It  may  begin  as  a 
thin  lamella  of  degenerated  tissue  on  the  external  surface  of  the  lateral 
column  in  the  lower  dorsal  region,  the  area  of  the  degeneration  gradually 
increasing  in  size  upwards  along  the  cord  and  the  external  surface  of  the 
restiform  bodies.  In  lesions  of  the  cauda  equina,  and  sometimes  after 
severe  traumatic  injui'ies  of  the  sciatic  nerve,  the  posterior  root-zones,  as 
well  as  the  columns  of  Goll,  undergo  ascending  degeneration  in  the  lumbar 
and  greater  portion  of  the  dorsal  regions,  but  the  degeneration  becomes 
limited  to  the  columns  of  Goll  in  the  upper  dorsal  and  cervical  regions. 


Fig.  147. 


Fig.  148. 


Fig.  149. 


Figs.  147, 148,  and  149.  Transverse  Sections  of  the  Spinal  Cord,  from  the  middle  of 
the  cervical  enlargement,  middle  of  the  dorsal  region,  and  middle  of  the  lumbar 
region  respectively,  showing  ascending  degeneration  of  the  column  of  Goll  (g), 
and  of  the  direct  cerebellar  tract  {dc). 

(6)  Descending  degeneration  occurs  in  all  destructive  lesions  of  the  brain 
or  spinal  cord  which  injure  the  fibres  of  the  pyramidal  tract  in  their 
passage  through  the  corona  radiata,  internal  capsule,  crus  cerebri,  pons, 


Fig.  151. 


Fig.  152. 


Figs.  150, 151,  and  152  (.Aiter  Charcot).  Transverse  Sections  of  the  Spinal  cord,  from 
the  middle  of  the  cercical  enlargement,  middle  of  the  dorsal  region,  and  middle  of 
the  lumbar  region  respectively,  showing  primary  lateral  sclerosis  of  the  cord,  or 
secondary  to  a  lesion  high  up  in  the  cord  or  medulla  oblongata.  —A,  A,  A,  De- 
generated pyramidal  tracts. 


96 


MORBID  ANATOMY  OF  THE 


Fig.  153. 


medulla,  or  cord.  In  the  diseases  of  the  cord,  the  degeneration  is  generally 
bilateral  and  symmetrical,  and  the  position  occupied  by  the  diseased  por- 
tions of  the  cord  in  the  lateral  columns  is  represented  in  Figs.  150,  151, 

and  152 ;  the  degeneration  of  the 
columns  of  Tiirck  is,  however,  not 
shown.  The  position  occupied  by  the 
diseased  portion  in  the  medulla  ob- 
longata is  represented  in  the  annexed 
woodcut  {Fig.  153,  A),  In  cerebral 
lesions  the  degenerative  tract  is  gene- 
rally limited  to  one  side— the  side  of  the 
cord  opposite  the  lesion  in  the  brain — 
as  represented  in  Figs.  154  to  156. 
The  columns  of  Tiirck  on  the  same 
side  as  the  lesion  of  the  brain  are  also 
usually  simultaneously  degenerated, 
but  this  is  not  represented  in  the 
figure. 


Fig.  153  (After  Charcot).  Transverse 
section  of  the  medulla  oblongata, 
on  a  level  with  the  middle  of  the 
olivary  body. — A,  A,  Sclerosis  of 
the  anterior  pyramids. 


Fig.  155. 


Figs.  154,  155,  and  156  (After  Charcot).  Transverse  Sections  of  the  Spinal  Cord,  from 
the  middle  of  the  cervical  enlargement,  middle  of  the  dorsal  ■^-egion,  and  middle  of 
the  lumbar  region  respectively,  showing  descending  sclerosis  of  the  pyramidal 
tract  in  the  lateral  column  secondary  to  a  cerebral  lesion. — A,  A,  A,  De- 
generated pyramidal  tract. 

3.  Degeneration  of  the  Spinal  Cord  Secondary  to  Amputation. — The 
changes  which  occur  in  the  spinal  cord  after  amputation  have  been  studied 
by  Berard,  Cruveilhier,  Tiirck,  Dickinson,  Lockhart  Clarke,  Vulpian,  and 
others ;  and,  in  a  recent  number  of  the  Journal  of  Anatomy  and  Physio- 
logy, Dr.  Dreschfeld  has  given  a  good  resumd  of  the  previous  observations 
of  others,  while  adding  new  observations  of  his  own.  The  general  result 
appears  to  be  that  the  peripheric  nerves  and  the  white  substance  of  the 
cord  are  unaffected,  the  posterior  roots  are  often  slightly  diminished  in 
size,  and  changes  in  the  ganglion  cells  of  the  anterior  horns  are  of  constant 
occurrence.  Some  of  the  ganglion  cells  of  the  anterior  horns  have  com- 
pletely disappeared,  whilst  those  that  remain  are  atrophied  and  shorn  of 
their  processes.  Judging  from  the  various  drawings,  the  ganglion  cells  of 
the  margins  of  the  various  groups  disappear  first,  and  those  of  their  centres 
remain  to  the  last.  The  cells  of  the  postero-lateral  group  are  particularly 
liable  to  be  affected.  No  mention  is  made  of  the  disappearance  of  any  of 
the  ganglion  cells  from  the  anterior  horn  on  the  side  opposite  to  that  of 


SPINAL   CORD  AND   MEDULLA  OBLONGATA.  97 

the  amputated  limb  ;  but  judging  from  the  diagrams  which  illustrate  Dr. 
Dreschfeld's  paper,  I  should  think  that  the  number  of  cells  in  the  internal 
group  of  the  opposite  side  is  much  diminished.  The  fibres  of  the  external 
fasciculus  of  the  posterior  root  pass  through  the  anterior  commissure  to 
join  the  cells  of  the  internal  group,  and  in  future  cases  it  would  be  worth 
while  to  observe  whether  a  streak  of  degeneration  might  not  be  detected 
along  the  course  of  these  fibres  to  reach  the  internal  group  of  the  opposite 
side.  Hayem  tore  out  the  sciatic  nerve  of  one  side  in  rabbits,  and  found 
in  the  lumbar  region  of  the  cord  on  the  same  side  sclerosis  of  the  posterior 
root  and  posterior  grey  matter,  along  with  degenerative  atrophy  of  the 
ganglion  cells  of  the  intermedio-lateral  tract. 

§  391.  Deformities  and  Malformations  of  the  Spinal  Cord. 

The  deformities  and  malformations  of  the  spinal  cord  may 
be  subdivided  into — (1)  the  congenital  deformities  which  are 
incompatible  with  the  maintenance  of  extra-uterine  life  ;  (2) 
the  congenital  deformities  which  are  compatible  with  life, 
and  do  not  betray  themselves  by  any  symptom  during  life  ;  (3) 
the  congenital  deformities  which  may  be  recognised  during  life  ; 
(4)  acquired  deformities  resulting  from  pathological  processes 
(Syringomyelia,  Hydromyelus  acquisitus)  (Leyden). 

The  following  are  the  more  frequent  conditions  observed 
(Leyden) : — 

1.  Congenital  Deformities  of  Still-born  Children. 

(a)  Amyelia,  or  absence  of  the  spinal  cord.  It  is  only  met  with  when 
the  brain  is  also  absent. 

(6)  Atelomyelia,  or  imperfect  development  of  the  spinal  cord.  The 
upper  end  of  the  cord  is  lacking  or  imperfectly  developed,  the  brain  being 
also  absent  (anencephalia),  or  the  head  defective  (acephalia).  The  me- 
dulla oblongata  is  absent  or  exists  only  in  a  rudimentary  form. 

(c)  Diastematomyelia  is  a  condition  in  which  the  two  lateral  halves  of 
the  cord  either  do  not  unite,  or  unite  only  throughout  a  portion  of  their 
extent.     This  malformation  occurs  with  anencephalia. 

{d)  Diplomydia,  or  duplication  of  the  spinal  cord,  appears  in  the  various 
forms  of  double  monsters. 

^1.  Congenital  Deformities  which  cannot  be  recognised  duriJig  Life. 
(a)  Anomalies  in  the  Length  and  Thickness  of  the  Cord. — The  cord  is 
found  at  times  thick  and  voluminous,  and  at  other  times  thin  and  small. 
It  descends  at  times  to  the  third  lumbar  vertebra,  and  ends  at  other  times 
opposite  the  eleventh  or  twelfth  dorsal. 

(6)  Abnormal  smallness  of  the  entire  spinal  cord  and  medulla  oblon- 
gata, with  corresponding  smallness  of  the  nerve  fibres  and  axis  cylinders, 
H 


98 


MOEBID  ANATOMY  OF   THE 


has  recently  been  described  by  F.  Schultze,  in  one  of  Friedreich's  cases  of 
"  hereditary  ataxy." 

(c)  Asymmetry  of  the  grey  substance,  showing  unequal  width  and  depth 
of  the  anterior  grey  horns  on  a  transverse  section. 

{d)  Abnormalities  of  the  Pyramidal  Tracts.  — Flechsig  has  recently 
shown  that  the  fibres  of  the  pyramidal  tracts  are  very  variable  in  their 
distribution.  Each  pyramid  may  send  its  mass  of  fibres  into  the  spinal 
cord,  either  entirely  crossed  or  only  partly  crossed,  or  down  the  anterior 
columns  almost  entirely  uncrossed.  These  tracts  are  absent  in  anence- 
phalous  monsters  (Flechsig). 

In  cases  of  congenital  absence  or  intra-uterine  arrest  of  development 
of  certain  extremities  atrophy  of  definite  portions  of  the  spinal  cord  may 
be  observed  producing  asymmetry,  which  is  limited  to  the  cervical  or 
lumbar  enlargement  according  to  the  extremity  afiected. 

In  a  case  of  congenital  talipes  equino- varus  of  both  legs,  I  found  the 
conus  medullaris  remarkably  thin  and  tapering.  On  transverse  section 
the  anterior  grey  horns  were  seen  to  be  deformed,  the  internal  border 
which  in  health  runs  parallel  with  the  anterior  fissure  being  drawn  out- 
wards and  backwards,  so  as  to  be  almost  in  a  line  with  the  anterior  border  of 

Fig.  157. 


Fig.  157.  Transverse  Section  of  the  upper  end  of  the  Conus  Medullaris  of  the  Spinal 
Cord,  from  a  case  of  congenital  talipes  equino-varus.—A,  P,  Anterior  and  posterior 
horns  respectively ;  i,  internal  group  showing  healthy  cells  ;  a,  anterior,  al, 
antero-laleral,  pi,  postero-lateral,  and  c,  central  groups  of  cells,  each  being 
represented  only  by  a  few  small  round  cells  without  processes. 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  99 

the  anterior  commissure.  The  ganglion  cells  of  the  internal  group  were  well 
developed,  although  it  was  displaced  from  its  usual  position  {Fig.  157,  i). 
A  few  cells  were  observed  in  the  posterolateral  area;  but  the  cells 
of  the  anterior,  central,  and  antero-lateral  groups  were  entirely  absent 
in  many  sections,  while  in  others  a  few  imperfectly-developed  cells  were 
observed  in  these  areas  {Fig.  157,  a,  c,  al).  The  fine  fibrillated  texture  of 
Gerlach's  network  and  the  small  glistening  nuclei  of  the  neuroglia  appeared 
to  have  been  replaced  by  a  loose  connective  tissue,  thickly  studded  with 
connective  tissue  corpuscles.  Mr.  Hardie  long  ago  maintained  that  con- 
genital talipes  is  due  to  an  arrest  of  development,  and  that  the  feet  occupy 
postures  similar  to  those  of  the  embryo. 

Unusual  outgrowths  or  absence  of  portions  of  the  grey  matter,  such  as 
of  the  tractus  intermedio-lateralis,  are  occasionally  met  with.  Duplica- 
tions of  one  of  the  grey  horns  for  a  longer  or  shorter  distance  have  also 
been  observed. 

3.  Congenital  Deformities  zvhich  may  be  recognised  during  Life. 

{a)  Congenital  Enlargement  of  the  Central  Canal,  a  condition  which  has 
been  variously  called  hydrorrhachis  interna,  hydromyelus,  or  hydromyelus 
congenitus.  In  the  lighter  grades  of  the  congenital  affections  the  central 
canal  in  the  fcetus  is  converted  into  a  cavity  varying  in  width  from  that 
of  an  ordinary  knitting  needle  to  that  of  a  crow's  quill.  The  canal  may 
extend  the  entire  length  of  the  cord,  but  is  at  other  times  restricted  to 
certain  portions,  generally  the  cervical  or  lumbar  enlargement,  while  the 
dilatation  may  occasionally  be  moniliform,  or  the  anterior  and  posterior 
walls  may  have  grown  together  across  the  middle  giving  rise  to  the 
appearance  of  a  double  canaL  The  cord  does  not  appear  to  undergo  any 
abnormal  changes  apart  from  the  displacement  of  its  various  segments 
occasioned  by  the  great  dilatation  of  the  canal. 

In  the  higher  grade  of  congenital  hydromyelus  either  the  spinal  cord 
disappears  entirely,  or  becomes  split  into  two  halves  for  a  greater  or  lesser 
distance,  while  the  cavity  of  the  central  canal  freely  communicates  with 
the  cavity  of  the  spinal  arachnoid  ;  the  hydrorrachis  interna  is  then  merged 
into  hydrorrachis  externa,  as  not  unfrequently  happens  in  spina  bifida. 

(b)  Spina  bifida  consists  of  an  abnormal  accumulation  of  fluid  within 
the  cavity  of  the  spinal  arachnoid,  associated  with  a  greater  or  lesser 
deformity  of  the  vertebral  column.  As  it  gives  rise  to  serious  symptoms 
during  life  it  will  be  subsequently  described  in  detail  along  with  the 
diseases  of  the  membranes  of  the  spinal  cord. 

4.  Acquired  Deformities  resulting  from  Pathological  Processes. 

{a)  Syringomyelia,  or  the  pathological  formation  of  cavities,  may  be 
caused  in  various  ways. 

(i.)  Cavities  are  formed  by  the  softening  of  the  central  portions  of  new 
formations,  such  as  gliomata,  gliomyxomata,  and  gliosarcomata.  The 
tumour  is  sometimes  so  completely  disintegrated  that  only  a  capsule  of 
connective  tissue  or  mere  traces  of  the  tumour  remain.     This  softening 


100  MOllBID  ANATOMY  OF   THE 

is  sometimes  initiated  by  hcemorrhage  into  the  interior  of  the  tumour. 
This  accident  is  particularly  apt  to  occur  in  the  teleangiectatic  varieties. 

(ii.)  Breaking  down  and  softening  of  apoplectic  foci. 

(iii.)  Central  softening  in  areas  of  grey  degeneration  and  chronic 
myelitis. 

(iv.)  Obstruction  of  lymph  channels  produced  by  the  pressure  of  a 
tumour  and  other  causes  (Westphal).  Cavities  have  been  formed  in  the 
spinal  cords  of  animals  subsequent  to  various  injuries,  and  these  have 
been  supposed  to  have  been  caused  by  obstruction  of  lymph  channels 
(Naunyn  and  Eichhorst). 

(b)  Hydromyehcs  acquisitus,  or  acquired  dilatation  of  the  central  canal, 
may  result  from  the  following  causes  : — 

(i.)  Peri-ependymal  myelitis,  which  consists  of  a  proliferation  of  the 
connective  tissue  surrounding  the  central  canal,  may  cause  secondary 
dilatation  by  the  shrinking  of  the  newly-formed  tissue  (Hallopeau). 

(ii.)  Chronic  meningitis,  by  producing  adhesions  of  the  pia  mater  to 
the  dura  mater  at  definite  points,  may  also  cause  dilatation  of  the  central 
canal,  probably  by  shrinking  of  the  newly-formed  tissue  (Simon). 

(iii.)  Obliteration  of  the  canal  at  one  point  may  lead  to  dilatation  of  the 
neighbouring  portions. 

The  cavities  vary  greatly  in  size.  They  may  indeed  be  only  a  few 
millimetres  in  length,  or  extend  the  entire  length  of  the  cord.  Their 
number  also  varies  ;  in  many  cases  one  only  is  found,  but  at  other  times 
a  large  number  of  them  may  be  present.  They  are  almost  always 
situated  near  the  centre  of  the  cord,  and  their  relations  to  the  central 
canal  can  only  be  determined  by  careful  examination.  The  transverse 
diameter  of  these  cavities  may  vary  from  that  of  a  needle  to  the  tip 
of  a  man's  little  finger.  On  transverse  section  their  form  is  roundish, 
oval,  or  angular,  and  their  contents  consist  of  light  and  clear  or  turbid  and 
yellowish  fluid. 

The  walls  of  the  cavities  may  be  smooth  and  firm,  and  are  often 
lined  with  a  layer  of  cylindrical  epithelium,  or  they  may  be  rough,  ragged, 
and  uneven.  Their  walls  may  also  be  dense,  and  formed  of  cirrhotic  tissue 
or  of  tissue  which  has  undergone  grey  degeneration,  or  of  the  various  new 
formations  which  have  already  been  described. 

The  symptoms  caused  by  the  formation  of  cavities  in  the  cord  depend 
entirely  upon  their  situation,  and  no  definite  disease  which  can  be 
recognised  during  life  can  be  ascribed  to  the  presence  of  these  cavities. 


(II.)— CLASSIFICATION  OF  THE  DISEASES  QF  THE  SPINAL 
CORD  AND  MEDULLA  OBLONGATA. 

§  392.  The  rule  which  has  hitherto  been  followed  in  this  work 

is  to  describe  first  the  simplest  and  most  elementary  diseases, 
and  to  reserve  consideration  of  the  most  complicated  affections 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  101 

to  the  last.  In  no  diseases  is  it  more  advisable  to  follow  this 
rule  than  in  those  affecting  the  spinal  cord  and  medulla  oblon- 
gata, with  their  membranes.  The  annexed  table,  in  which 
these  diseases  are  classified,  carries  with  it  in  the  main  its  own 
explanation,  but  it  may  not  be  out  of  place  to  make  a  few 
remarks  with  regard  to  the  principle  adopted  in  arranging  the 
structural  diseases  of  the  nervous  organs  themselves  as  dis- 
tinguished from  those  of  their  membranes  and  vessels,  their 
functional  affections,  injuries,  malformations,  and  neoplasms. 

It  has  already  been  remarked  that  the  spinal  cord  may  be 
divided  into  longitudinal  segments,  each  of  which  possesses 
a  functional  unity,  and  may  be  separately  diseased.  Diseases 
of  one  of  the  functional  segments  of  the  cord  are  called 
system-diseases  or  fasciculated  diseases,  while  those  involving 
several  of  these  segments  may  be  called  mixed  diseases.  In 
the  simple  system-diseases  one  functional  segment  of  the  cord 
and  medulla  oblongata  alone  is  affected;  but  it  sometimes 
happens  that  two  or  more  of  them  become  simultaneously  or 
consecutively  attacked,  and  these  affections  may  be  called  com- 
pound system-diseases. 

The  system-diseases  may  be  divided  into  those  affecting  the 
grey  matter  or  the  poliomyelopathies,  and  those  affecting  the 
white  matter  or  the  leucomyelopathies.  The  poliomyelopathies 
may  be  subdivided  into  the  diseases  affecting  the  anterior  grey 
horns,  the  central  grey  column,  and  the  posterior  grey  horns; 
but  the  latter  is  never  a  true  system-disease,  being  always  com- 
plicated by  lesions  of  other  structures,  such  as  the  posterior 
roots  and  posterior  columns.  Disease  of  the  central  column  is 
also  probably  never  observed  as  an  isolated  affection,  the  promi- 
nent symptoms  being  caused  by  extension  of  the  lesion  into  the 
anterior  horns;  but  we  shall  nevertheless  classify  some  at  least  of 
the  diseases  of  the  central  column  amongst  the  system-diseases. 

The  leucomyelopathies  consist  theoretically  of  diseases  of  the 
posterior  root-zone  (locomotor  ataxy) ;  of  the  anterior  root-zone, 
disease  of  which  is  probably  not  capable  of  being  separated 
from  disease  of  the  anterior  roots  and  anterior  grey  horns ;  of 
the  column  of  GoU  and  the  direct  cerebellar  tract,  to  both  of 
which,  however,  no  definite  symptoms  have  been  observed  to 
attach,  and  of  the  pyramidal  tract  (primary  lateral  sclerosis). 


102  MORBID  ANATOMY   OF   THE 

The  compound  system-diseases  are  probably  numerous,  but 
only  one  of  them — amyotrophic  lateral  sclerosis — is  recognised 
as  a  distinct  type  of  disease.  The  annexed  diagram  (Fig.  158), 
copied  from  Charcot,  represents  the  localisation  of  the  lesion  on 
transverse  section  of  the  cord  in  the  various  system-diseases. 

In  the  mixed  diseases  of  the  spinal  cord  and  medulla  oblon- 
gata Landry's  paralysis  is  first  mentioned,  not  because  it  has 
been  proved  to  be  connected  with  anatomical  changes  in  the 
cord,  but  because  it  is  closely  allied  clinically  with  the  acute 
forms  of  central  myelitis.  The  classification  adopted  of  the 
different  forms  of  acute  and  chronic  myelitis  does  not  require 
any  explanation. 

Fig.  158. 


--1  ^ 


'      --~^^ 

-^v. 

I 

/ 

\ 

' 

r         -" 

-'" 

,^^\\ 


iniSiSSii   M^-L, 


iiP^~- 


Fig.  158  (After  Charcot).  Diagram  of  the  Morbid  Anatomy  of  the  System-Diseases 
<f  thi-  Spinal  Cord.  —A,  A,  Pyramidal  tract  of  the  lateral  column  ;  A',  Columns 
of  Tiirck  ;  B,  B.  Posterior  root-zones  ;  C,  C,  Posterior  grey  horns  ;  D,  D, 
Anterior  horn  ;  F,  F,  Anterior  root-zone  ;  E,  Columns  of  Goll. 


A.  Diseases  of  the  Spinal  Cord  and,  Medidla  Oblongata. 

I.  System  diseases. 

(i.)  Poliomyelopathies. 

1.  Poliomyelitis  anterior  acuta. 

(a)  Infantile  spinal  paralysis. 

(6)  Atrophic  spinal  paralysi.s  of  adults. 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  103 

2.  Poliomyelitis  anterior  chronica. 

3.  Progressive  muscular  atrophy. 

4.  Labio-glosso-laryngeal  paralysis. 

5.  Pseudo-hypertrophic  paralysis. 

(ii.)  Leucomyelopathies. 

1.  Posterior  sclerosis  (Locomotor  ataxy). 

2.  Sclerosis  of  the  columns  of  Goll. 

(a)  Primary. 

(6)  Secondary  and  Ascending. 

3.  Sclerosis  of  the  direct  cerebellar  tract.     Secondary  and 

Ascending  sclerosis. 

4.  Lateral  sclerosis. 

(a)  Primary — Tabes  dorsalis  spasmodica. 
(6)  Compound — (i.)   Amyotrophic  lateral  sclerosis, 
(ii.)  Combined  posterior  and  lateral 
sclerosis, 
(c)  Secondary  and  Descending. 

II.  Mixed  diseases  of  the  spinal  cord  and  medulla  oblongata. 

(i.)  Paralysis  ascendens  acuta  (Landry's  paralysis). 
(il)  Acute  myelitis. 

1.  Acute  central  myelitis. 

2.  Hyperacute  central  myelitis  (haematomyelitis). 

3.  Acute  bulbar  myelitis. 

4.  Acute  transverse  myelitis. 

5.  Acute  hemilateral  myelitis. 

6.  Acute  myelomeningitis. 

7.  Acute  disseminated  myelitis. 

(ill.)  Chronic  myelitis. 

1.  Chronic  central  myelitis. 

2.  Chronic  transverse  myelitis. 

3.  Universal  progressive  myelitis. 
■  4.  Chronic  bulbar  myelitis. 

5.  Chronic  myelomeningitis. 

6.  Chronic  disseminated  myelitis  or  multiple  sclerosis. 

(iv.)  Myelomalacia. 

III.  Vascular    diseases   of    the    spinal    cord    and    medulla 
oblongata. 

(i.)  Anaemia,  Thrombosis,  and  Embolism, 
(ii.)  Hypersemia  and  Haemorrhage. 


104  MORBID  ANATOMY  OF  THE  SPINAL   CORD. 

IV.  Functional  and  secondary  diseases  of   the   spinal  cord 
and  medulla  oblongata. 

(i.)  Spinal  irritation, 
(ii.)  Neurasthenia  spinalis. 
(hi.)  Reflex  and  secondary  paraplegise. 
(iv.)  Saltatory  spasms, 
(v.)  Reflex  muscular  spasms, 
(vi.)  Intermittent  spinal  paralysis. 
(vii.)  Toxic  spinal  paralysis, 
(viii.)  Hysterical  paraplegia. 

V.  Traumatic    diseases,  tumours,  and  abnormalities  of  the 
spinal  cord  and  medulla  oblongata. 

(i.)  Wounds  of  the  cord  and  of  the  medulla  oblongata, 
(ii.)  Slow  compression  of  the  cord  and  of  the  medulla 

oblongata. 
(hi.)  Hemiparaplegia  spinalis, 
(iv.)  Concussion. 

(v.)  Tumours,  and  abnormalities  of  the  spinal  cord  and 
medulla  oblongata. 

B.  Diseases  of  the  Membranes  of    the  Spinal   Cord  and 
Medulla  Oblongata. 

I.  Vascular  diseases. 

(i.)  Hyperaemia  of  the  membranes. 
(ii.)  Meningeal  haemorrhage. 

II.  Inflammation  of  the  spinal  dura  mater. 

(l.j  External  pachymeningitis, 
(ii.)  Internal  pachymeningitis. 

III.  Inflammation  of  the  spinal  pia  mater  and  arachnoid. 
(i.)  Acute  spinal  leptomeningitis. 

(ii.)  Chronic  spinal  leptomeningitis. 

IV.  Tumours  and  abnormalities  of  the  membranes. 


105 


CHAPTER    III. 


I.— SYSTEM   DISEASES    OF    THE    SPINAL    CORD    AND 
MEDULLA    OBLONGATA. 

(I.)    POLIOMYELOPATHIES. 


1.  Poliomyelitis  Anterior  Acuta  (Kussmaul). 

Acute  Inflammation  of  the  Grey  Anterior  Horns. — Acute  Atrophic  Spinal  Paralysis. 

§393.  Definition. — Acute  atrophic  spinal  paralysis  begins 
suddenly  with  fever,  general  convulsions,  or  other  cerebral 
symptoms,  and  paralysis  which  reaches  its  maximum  intensity 
at  once.  The  paralysis  is  variable  in  its  distribution,  the 
affected  muscles  are  flaccid,  reflex  action  is  diminished  or 
abolished,  some  of  the  muscles  implicated  undergo  rapid 
atrophy,  and  there  is  entire  absence  of  sensory  disturbances 
and  of  disorders  of  the  functions  of  the  bladder  and  rectum. 

§  394.  History.— This  disease  was  first  described  by  Underwood  in 
1784,  but  he  did  not  separate  it  distinctly  from  other  forms  of  paralysis  to 
which  children  are  liable.  The  affection,  indeed,  does  not  appear  to  have 
attracted  much  notice  until  Heine,  in  1840,  directed  particular  attention 
to  it.  A  good  description  of  it  was  given  by  Barthez  and  Rilliet,  in 
1851 ;  but  it  was  much  more  thoroughly  investigated  about  the  same 
time  by  Duchenne,  who  named  it  parali/sie  atrophique  graisseuse  de 
fenfance.  In  1864,  two  monographs  appeared — the  thesis  of  Duchenne 
the  younger,  and  that  of  Laborde — both  of  which  are  very  important  on 
account  of  the  wealth  of  clinical  facts  contained  in  them.  Dr.  Miiller 
has  recently  collected  and  analysed  all  the  published  cases  of  atrophic 
spinal  paralysis  in  the  adult  from  the  time  of  Duchenne  to  the  present  day. 

§  395.  Etiology.— Hhe  most  remarkable  feature  with  respect 
to  the  etiology  of  this  paralysis  is  the  strong  predisposition  to 
the  affection  manifested  by  the  age  of  childhood.  In  thirty-two 
out  of  forty-four  cases  observed  by  Dr.  West,  the  disease  came 


106  SYSTEM  DISEASES   OF   THE 

on  between  the  age  of  six  months  and  three  years  ;  while,  if  we 
analyse  the  cases  collected  by  Heine,  Duchenne  the  younger, 
and  those  observed  by  Barlow,  more  than  three-fourths  (154  out 
of  205)  of  all  the  cases  occurred  between  the  age  of  six  months 
and  two  years.  But  Duchenne  reports  a  case  in  a  child  twelve 
days  old,  and  another  in  a  child  a  month  old,  while  essentially 
the  same  disease  occurs  in  the  adult. 

Sex  does  not  appear  to  exercise  any  influence  in  its  pro- 
duction, nor  has  any  direct  or  indirect  hereditary  tendency  to  the 
affection  been  traced.  Heine,  indeed,  asserts  that  the  disease 
attacks  by  preference  the  healthiest  and  most  robust  children. 

The  disease  appears  to  be  most  common  during  the  summer 
months ;  thus,  out  of  fifty- three  cases  in  which  the  date  of 
attack  could  be  fixed  with  accuracy  by  Dr.  Barlow,  twenty-seven 
occurred  in  the  months  of  July  and  August. 

The  exciting  causes  of  the  affection  are  equally  obscure,  and 
it  occurs  frequently  in  the  midst  of  robust  health.  Of  all  the 
alleged  causes,  difficult  or  even  normal  dentition  is  the  one  most 
frequently  assigned ;  and  it  is  probable  that  too  much  rather 
than  too  little  importance  has  been  attributed  to  this  process  in 
the  production  of  the  affection.  Injuries  of  various  kinds  are 
often  assigned  as  causes  of  the  disease;  while  nurses  are  fre- 
quently blamed  unjustly  by  parents,  who,  unable  to  believe  that 
such  a  striking  phenomenon  as  paralysis  can  occur  suddenly 
without  appreciable  cause,  imagine  that  the  child  has  been  lamed 
by  a  fall  through  the  carelessness  of  its  attendant. 

Exposure  to  cold,  more  especially  when  the  body  is  over- 
heated, appears  to  have  immediately  preceded  the  paralysis  in 
a  considerable  number  of  cases ;  and  the  affection  often  occurs 
in  children  during  the  progress  or  soon  after  an  attack  of  measles, 
scarlatina,  smallpox,  typhus,  and  other  acute  affections. 

§  396.  Symptoms. — Although  this  disease  is  essentially  the 
same  in  children  and  in  adults,  yet  the  symptoms  in  each  differ 
so  much  as  to  demand  separate  description.  The  disease  as  it 
occurs  in  children  will  be  first  described. 

{a)  Infantile  Spinal  Paralysis. 
It  will  conduce  to  clearness  of  description  if,  like  Laborde,  we 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  107 

divide  the  clinical  history  of  this  affection  into  four  periods  : 
(1)  Invasion  ;  (2)  Remission  ;  (3)  Regression  of  paralytic  pheno- 
mena ;  (4)  Atrophy  and  deformities.  It  must,  however,  be 
remembered  that  these  periods  overlap,  instead  of  being  dis- 
tinctly separated  from  each  other,  and  that  this  subdivision 
is  merely  adopted  for  the  sake  of  convenience. 

(1)  Period  of  Invasion. — The  disease  is  commonly  ushered 
in  by  a  more  or  less  intense  fever,  which  is  often  preceded  by 
general  malaise,  pain  in  the  head,  mental  irritability,  fretfulness, 
and  startings.  The  fever  is  as  a  rule  of  short  duration,  lasting 
only  from  one  to  two  days.  In  some  cases  it  passes  off  in  a  few 
hours,  while  in  other  cases  it  may  continue  from  six  to  fourteen 
days,  or  even  longer.  As  the  fever  becomes  established  the  cere- 
bral symptoms  become  more  pronounced,  confusion  of  ideas  and 
slight  somnolency  are  observed,  the  child  may  become  uncon- 
scious, or  delirium  of  varying  degrees  of  intensity  may  supervene. 

The  disease  is  not  unfrequently  ushered  in  by  convulsions. 
Sometimes  the  paralysis  occurs  after  a  single  convulsion  of 
short  duration,  while  at  other  times  they  are  repeated  many 
times  at  variable  intervals  before  the  paralysis  is  definitely 
declared  (Laborde).  The  convulsions,  according  to  Laborde, 
often  assume  the  tonic  form,  the  spasms,  as  a  rule,  being  re- 
stricted to  the  extremities,  and  only  extending  on  rare  occasions 
to  the  face  ;  and  he  belieVes  that  even  in  these  latter  cases  the 
attacks  are  unaccompanied  by  any  other  cerebral  symptoms. 
But  in  one  of  the  cases  quoted  by  Laborde  in  support  of  this 
opinion  the  convulsion  was  accompanied  by  unconsciousness, 
so  that  there  are  not  sufficient  grounds  for  believing  that 
these  attacks  differ  in  any  way  from  ordinary  eclamptic  attacks 
so  common  in  children.  In  the  cases  ushered  in  by  convul- 
sions fever  is  often  not  mentioned  as  having  been  present, 
but,  as  Laborde  suggests,  it  is  probable  that  the  convulsions 
assume  such  paramount  proportions  in  the  minds  of  the  atten- 
dants that  minor  symptoms  are  not  observed.  In  some  few  cases 
all  general  symptoms  are  absent,  the  child  is  put  to  bed 
apparently  in  good  health  and  is  found  in  the  morning  paralysed. 
In  most  of  these  cases  the  paralysis  is  limited  to  a  portion  of  a 
limb,  indicating  that  the  primary  lesion  is  circumscribed.  It 
is,  however,  probable  that  in  many  of  these  cases  transitory 


108  SYSTEM   DISEASES   OF   THE 

fever  and  other  general  symptoms  may  have  been  present,  and 
overlooked  owing  to  the  defective  observation  of  parents. 

(2)  Period  of  Remission. —  The  initial  symptoms  subside  in  a 
few  days  and  the  general  health  improves,  but  when  the  child 
is  taken  out  of  bed  to  be  bathed,  or  for  some  other  purpose,  it 
is  observed  for  the  first  time  that  one  or  all  the  limbs  hang 
down  relaxed  and  powerless.  The  paralysis  is  as  a  rule  developed 
with  great  rapidity,  probably  never  with  the  instantaneousness' 
of  that  caused  by  cerebral  haemorrhage  ;  but  it  creeps  on  some- 
what gradually  during  several  hours,  half  a  day  or  a  night 
before  attaining  its  acme.  In  some  few  cases  the  paralysis 
may  spread  more  slowly,  and  not  reach  its  maximum  for  several 
days.  In  other  cases  two  or  more  attacks  of  paralysis  succeed 
one  another;  at  the  first  one  limb  is  affected,  and  this  is 
followed  by  improvement,  but  the  child  relapses  in  a  few  days 
into  a  feverish  state,  when  another  limb  is  found  paralysed 
(Althaus).  Still  more  remarkable  cases  are  recorded  by 
Laborde,  in  which  the  paralysis  did  not  become  permanently 
established  until  the  third  attack. 

But  notwithstanding  slic^ht  variations,  one  of  the  most 
characteristic  features  of  this  affection  is  that  the  paralysis 
reaches  its  maximum  of  extent  and  intensity  within  a  com- 
paratively brief  space  of  time  from  the  onset.  The  paralysis 
possesses  no  progressive  character ;  it  recedes  but  does  not  ad- 
vance further. 

The  distribution  of  the  'paralysis  is  exceedingly  variable.  It 
is  frequently  general,  involving  the  muscles  of  the  four 
extremities,  as  well  as  a  great  part  of  the  muscles  of  the  trunk, 
especially  those  of  the  vertebral  column,  and  sometimes  those 
of  the  neck.  It  also  frequently  assumes  the  paraplegic  form ; 
but  the  upper  extremities  are  probably  never  exclusively  affected. 
The  disease  occasionally  presents  itself  in  the  form  of  a  hemi- 
plegia (Duchenne  fils,  Barlow),  and  in  these  cases  the  side  of  the 
neck,  of  the  face,  and  of  the  tongue  may  be  implicated  at  first 
but  do  not  remain  permanently  paralysed. 

The  sensibility  is  almost  entirely  unaffected  throughout  the 
whole  progress  of  the  disease.  At  the  outset  of  the  affection 
patients  may  complain  of  pains  and  parsesthesise,  but  these 
symptoms  are  of  short  duration.     A  certain  degree  of  cutaneous 


SPINAL   COED    AND   MEDULLA   OBLONGATA.  109 

hypersesthesia,  or  rather  hyperalgesia,  has  been  described  as 
being  present  during  the  febrile  stage,  but  the  tenderness  to 
touch  described  may  have  been  due  to  affections  of  deeper 
structures,  such  as  rheumatic  inflammation  of  joints. 

Reflex  action,  both  cutaneous  and  tendinous,  is  completely 
abolished  in  all  the  muscles  which  are  severely  attacked,  and  it 
is  much  lowered  or  temporarily  extinguished  in  those  muscles 
that  are  only  slightly  affected. 

The  functions  of  the  bladder  and  rectum  are  rarely  affected. 
During  the  first  days,  however,  there  may  be  retention  of  urine, 
but  more  frequently  there  is  incontinence,  and  the  stools  may  be 
passed  involuntarily.  In  young  children  a  slight  weakness  of 
the  bladder  with  occasional  incontinence  may  remain  for  some 
time,  but  as  a  rule  all  disturbances  of  the  bladder  and  rectum 
have  disappeared  in  from  three  to  eight  days  from  the  onset  of 
the  disease. 

(3)  Period  of  Regression. — After  a  certain  time,  which  varies 
from  a  few  days  to  a  few  weeks,  a  gradual  improvement  of  the 
paralysis  takes  place.  This  improvement  may  affect  a  greater 
or  smaller  number  of  the  muscles  involved,  and  some  authors 
think  that  all  the  paralysed  muscles  may  completely  recover. 
The  cases  in  which  complete  recovery  takes  place  have  been 
called  temporary  spinal  paralysis  (Kennedy).  Dr.  Edge,  of 
Manchester,  reports  an  interesting  case  which  appears  to  have 
belonged  to  this  category.  It  was  the  case  of  a  boy,  aged  ten 
years,  in  whom  the  muscles  of  both  extremities  as  well  as  those 
of  the  back  were  paralysed.  Some  of  the  paralysed  muscles 
were  slightly  atrophied,  the  faradic  contractility  was  diminished, 
there  were  no  bed-sores,  and  no  disturbances  in  the  functions 
of  the  bladder  or  rectum  ;  but  there  was  transitory  impairment 
of  cutaneous  sensibility  in  the  lower  extremities.  Recovery 
was  complete  in  four  weeks  from  the  commencement  of  the 
attack. 

As  a  rule,  however,  there  is  only  complete  restitution  of  some 
of  the  muscles,  while  the  rest  remain  permanently  paralysed. 
The  mode  in  which  the  paralysis  recedes  is  peculiar.  In  six 
cases  of  generalised  paralysis,  which  Laborde  had  the  oppor- 
tunity of  observing  accurately  from  the  commencement  of  the 
attack,  the  paralysis  in  the  upper  half  of  the  body  began  to 


110  SYSTEM  DISEASES   OF  THE 

improve  between  the  third  to  the  fifteenth  day  from  the 
commencement;  and  it  disappeared  rapidly  from  the  neck, 
upper  extremities,  and  trunk,  and  became  restricted  to 
the  lower  extremities.  This  improvement  Laborde  calls  the 
period  of  first  regression,  inasmuch  as  it  is  followed  after  a 
variable  interval  of  time  by  a  second  period  of  amendment 
which  he  calls  the  second  regression.  During  the  second 
regression  there  is  a  gradual  improvement  of  the  paralysis  in 
both  lower  extremities,  and  the  muscles  of  one  of  them  may  be 
completely  restored  to  full  power;  but  the  paralysis  becomes 
permanently  established  in  one  or  more  groups  of  the  muscles 
of  the  other  lower  extremity,  the  anterior  and  external  group 
of  muscles  being  those  most  frequently  left  paralysed.  But, 
although  the  improvement  usually  takes  place  from  above 
downwards,  it  sometimes  occurs  in  the  reverse  order,  and  then 
the  paralysis  becomes  permanently  localised  in  a  superior  ex- 
tremity ;  and  in  rare  cases  it  becomes  localised  in  the  muscles 
of  the  trunk  or  neck.  In  the  case  of  a  child  two  years  of  age, 
under  the  care  of  Dr.  Simon  at  the  Southern  Hospital,  the 
muscles  of  the  neck  alone  remained  paralysed,  and  all  of  these 
were  completely  paralysed  and  atrophied. 

The  chiefs  facts  which  concern  us  in  this  affection  are  that 
the  paralysis  reaches  its  maximum  of  extent  and  intensity  at 
once ;  that  in  all  cases,  without  exception,  improvement  occurs 
in  some  of  the  paralysed  muscles ;  that  the  improvement 
proceeds  most  actively  during  the  first  four  to  eight  weeks,  and 
subsequently  at  a  much  slower  rate;  and  that  this  improvement 
mav  continue  for  from  six  to  nine  months,  and  under  appropriate 
treatment  may  go  on  for  one  or  two  years  from  the  commence- 
ment of  the  attack. 

(4)  Period  of  Atrophy  and  Deformities. — All  muscles,  in 
which  motor  power  is  not  soon  restored,  become  the  subjects  of 
a  rapidly  progressive  atrophy ;  and  even  the  muscles  which 
are  but  slightly  affected  emaciate  to  some  extent,  but  soon 
recover  on  the  restoration  of  voluntary  power. 

The  atrophy  usually  begins  in  the  first  week  of  the  disease, 
and  it  is  generally  well  marked  in  the  course  of  a  few  weeks  in 
the  muscles  which  are  severely  affected.  The  muscles  become 
more  and  more  flaccid  and  attenuated,  and  after  a  time  may 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  HI 

disappear  so  completely  that  the  skin  seems  to  lie  immediately 
upon  the  bone.  But  the  extent  of  the  atrophy  of  the  muscular 
substance  is  not  always  exactly  measured  by  the  loss  of  bulk  of  the 
muscle,  inasmuch  as  the  amount  of  atrophy  is  frequently  masked 
by  the  accumulation  of  fat  in  the  connective  tissue.  At  times, 
indeed,  the  volume  of  the  muscle  appears  to  be  increased,  owing 
to  the  fatty  accumulation,  giving  rise  to  the  condition  which 
Duchenne  has  called  pseudo-hypertrophy ;  but  in  these  cases 
advanced  atrophy  can  be  readily  recognised  by  the  extreme 
flaccidity  and  doughy  feeling  of  the  affected  muscles  when 
compared  with  the  healthy. 

The  condition  of  the  electrical  irritability  of  the  motor  nerves 
and  muscles  deserves  special  attention.  Duchenne  was  the  first 
to  use  the  faradic  current  as  a  test  of  the  degree  of  alteration 
in  the  muscles;  and  he  found  that  the  faradic  irritability  of 
both  nerves  and  muscles  begins  to  sink  quickly  in  those 
which  are  severely  affected.  He  found,  indeed,  that  it  was 
materially  diminished  at  the  end  of  three  to  fiye  days,  and 
entirely  abolished  by  the  seventh  day  or  during  the  course  of 
the  second  week.  He  also  laid  down  a  rule  which  has  been  con- 
firmed by  all  subsequent  observers,  and  the  practical  importance 
of  which  it  is  difficult  to  exaggerate — viz.,  that  all  the  paralysed 
muscles  in  which  the  faradic  irritability  is  only  more  or  less 
diminished,  but  not  completely  lost,  during  the  course  of  the 
second  week,  do  not  remain  permanently  paralysed,  the  restora- 
tion being  the  more  prompt  and  complete  the  less  their  faradic 
irritability  has  been  diminished. 

The  galvanic  irritability  was  first  investigated  by  Solomon, 
who  showed  that  the  course  of  the  alteration  resembled  that 
of  severe  traumatic  paralysis.  There  is  rapid  loss  of  galvanic 
irritability  in  the  nerves  during  the  first  two  weeks  of  the 
paralysis,  and  the  irritability  of  the  muscles  manifests  the 
qualitative  changes  which  characterise  the  reaction  of  degenera- 
tion. During  the  first  weeks  of  the  paralysis  there  is  an 
increase  of  the  galvanic  irritability,  the  contraction  on  anodal 
is  stronger  than  on  cathodal  closure,  and  the  contraction  is 
sluggish  and  protracted,  instead  of  being  instantaneous  as  in 
health.  In  the  course  of  two  or  three  months  the  galvanic 
irritability  sinks  again  much  below  the  normal  standard,  but 


112  SYSTEM   DISEASES   OF  THE 

retains  the  characteristic  qualitative  alterations,  and  in  the 
course  of  one  or  two  years  from  the  beginning  of  the  disease 
there  is  only  a  trace  of  it  generally  left.  In  the  muscles  that 
do  not  atrophy,  and  in  those  which  have  regained  their  motor 
power,  a  greater  or  lesser  diminution  in  the  faradic  and  galvanic 
irritability  is  generally  found,  but  the  reaction  of  degeneration 
is  absent. 

Arrest  of  development  of  the  osseous  system  is  an  important 
symptom  to  which  Duchenne  and  Yolkmann  have  directed 
special  attention.  The  atrophy  of  the  bones  has  no  necessary 
relation  with  that  of  the  muscles.  The  greater  part  of  the 
muscles  may  indeed  be  lost  in  a  limb,  while  the  bones  are 
almost  entirely  unaffected  ;  and,  conversely,  a  limb  may  be 
considerably  shortened,  while  only  one  or  two  muscles  are 
atrophied.  Volkmann  has  indeed  described  cases  in  which  the 
motor  paralysis  was  temporary,  and  followed  after  a  few  days 
by  a  complete  return  of  motor  functions,  but  where  the  trophic 
lesions  of  the  bones  persisted  during  life. 

The  paralysed  leg  may  after  some  years  be  found  from  two 
to  six  inches  shorter  than  the  sound  limb ;  and  the  upper  ex- 
tremity may  be  similarly  shortened,  although  not  generally  to 
the  same  degree.  The  long  bones  are  thinner  than  normal, 
they  are  porous,  friable,  and  yielding.  Their  epiphyses  and 
processes  grow  smaller  and  less  distinct;  the  paralysed  hand  or 
foot  is  shorter,  narrower,  and  thinner  than  the  sound  one  ;  and 
even  the  pelvis  may  be  arrested  in  its  development. 

The  joints  become  deformed  and  unusually  movable.  The 
increased  mobility  of  the  joints  is  caused  partly  by  the  dis- 
appearance of  the  articular  extremities  of  the  bones,  and  partly 
by  relaxation  and  stretching  of  their  ligaments.  The  relaxation 
of  the  latter  is,  indeed,  sometimes  so  great  that  the  patient  can 
dislocate  a  joint  without  experiencing  any  discomfort. 

The  shin  of  the  affected  extremity  becomes  flabby;  its 
loss  of  elasticity  being  manifested  by  long  retention  of  slight 
pressure  marks,  such  as  that  produced  by  the  stocking.  The 
surface  of  the  limb  assumes  a  mottled  or  bluish  colour,  and 
it  is  remarkably  cold  to  the  touch;  the  reduction  of  tem- 
perature in  old-established  cases  being,  according  to  Heine,  as 
much  as  10°  to  12°  F.,  as  compared  with  the  corresponding 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  113 

healthy  limb.  The  skin  is  liable  to  be  affected  with  chilblains, 
ulcers  which  are  slow  in  healing  form  on  slight  provocation, 
whilst  the  defective  nutrition  and  great  coldness  of  the  skin 
often  cause  a  certain  diminution  of  cutaneous  sensibility.  The 
nutritive  and  vascular  changes  in  the  affected  extremity  are 
accompanied  by  diminution  in  the  calibre  of  the  arteries 
(Charcot). 

Deformities. — The  various  deformities  which  occur  in  the 
affected  limbs  in  infantile  spinal  paralysis  furaish  very 
characteristic  features  of  the  disease.  Various  opinions  have 
been  held  by  different  authors  with  respect  to  the  mechanism 
by  which  these  deformities  are  produced.  Some  pathologists 
believe  that  the  healthy  muscles  are  always  maintained  in  a 
condition  of  moderate  contraction,  constituting  the  normal 
tonus  of  the  muscles,  and  when  this  tonus  is  destroyed  by 
paralysis  in  a  certain  group  of  muscles,  the  predominant  action 
of  their  healthy  antagonists  produces  a  deformity.  Volkmann, 
however,  denies  the  existence  of  muscular  tonus,  and  thinks  that 
the  deformity  is  mainly  produced  by  the  weight  of  the  limb 
itself  He  points  out  that  in  paralytic  deformities  of  the  lower 
extremities,  the  position  generally  assumed  by  the  foot  is  only 
a  high  degree  of  that  which  it  takes  when  unsupported  and  left 
free  from  the  action  of  the  muscles.  The  weight  of  the  limb 
and  the  direction  in  which  mechanical  forces  act  upon  it  during 
locomotion  are  undoubtedly  important  causes  of  deformities  ; 
but  two  other  co-operating  factors  may  be  mentioned.  The 
paralysed  muscles  permit  the  limb  frequently  to  assume  a 
position  in  which  the  ends  of  their  healthy  antagonists  are  more 
or  less  permanently  approximated,  and  the  latter  consequently 
undergo  adapted  atrophy  (Adams),  and  become  permanently 
shortened.  The  second  factor  consists  of  an  affection  of  the 
paralysed  muscles  themselves.  The  atrophied  muscles  are 
probably  at  times,  like  the  bones,  the  subjects  of  arrested 
development ;  their  growth  does  not  keep  pace  with  that  of 
the  healthy  muscles  and  of  the  body  generally,  hence  they 
become  permanently  shortened.  Some  have  supposed  that 
proliferation  of  the  interstitial  connective  tissue  and  its  subse- 
quent retraction  may  occur  in  the  course  of  the  atrophy  of  the 
muscles,  and  thus  lead  to  permanent  shortening  in  them  ;  but 
I 


114  SYSTEM  DISEASES   OF  THE 

this  is  doubtful.  When  the  deformity  is  caused  by  shortening 
of  the  paralysed  muscles,  the  latter  are  found  in  the  concavity  of 
the  distorted  extremity.  But  whatever  may  be  the  mechanism 
by  which  these  deformities  are  produced,  it  would  seem  that, 
disregarding  a  certain  degree  of  inequality  and  disfigurement 
caused  by  the  arrest  of  development  of  the  long  bones,  paralysis 
of  certain  muscles  and  groups  of  muscles,  along  with  relaxation 
of  the  ligaments,  is  the  main  cause  of  the  various  distortions 
observed. 

Some  of  the  muscles  of  one  lower  extremity  suffer  more 
frequently  than  others  from  permanent  paralysis  ;  and  of  these 
the  antero-external  group  of  the  leg — the  long  extensor  of  the 
toes,  tibialis  anticus,  special  extensor  of  the  great  toe,  and  the 
long  and  short  peronei — are  those  most  commonly  affected. 
The  most  frequent  forms  of  paralytic  talipes  are,  therefore,  as 
might  have  been  expected,  talipes  equinus  and  equino-varus 
(Plate  II.,  5),  When  the  anterior  group  and  the  adductors  of  the 
foot  are  affected  at  the  same  time  talipes  equino-varus  results ; 
and  when  the  muscles  of  the  calf  are  alone  affected  talipes  calca- 
neus is  produced,  but  this  form  is  exceedingly  rare  ;  and  simple 
paralytic  talipes  varus  is  of  still  rarer  occurrence.  Another 
common  deformity  is  the  "  pes  cavus" — "talus  pied  creux"  of  the 
French — in  which  the  sole  is  hollowed  and  the  instep  rendered 
prominent.  Duchenne  thinks  it  is  caused  by  a  more  or  less 
complete  paralysis  of  the  muscles  of  the  calf,  along  with 
simultaneous  contraction  of  the  flexors  of  the  foot,  either  the 
long  flexor  of  the  toes  or  the  long  peroneus.  The  great  laxity 
of  the  ligaments  of  the  foot  allows  the  latter  to  become  bent 
upon  itself  from  the  transverse  tarsal  joint,  where  the  foot  is 
unsupported ;  but  when  it  is  placed  upon  the  ground  it  assumes 
the  form  of  "  flat  foot." 

Various  deformities  occur  in  the  inferior  extremity,  according 
to  the  extent  and  localisation  of  the  paralysis.  The  anterior 
and  internal  muscles  of  the  thigh  are  most  usually  affected 
above  the  knee,  and  in  that  case  the  predominant  action  of  the 
flexors  of  the  leg  on  the  thigh  maintains  the  former  in  a  per- 
manent condition  of  partial  flexion  (Genu  recurvatum),  the  leg 
being  also  abducted.  The  condition  is  always  associated  with 
talipes  equino-varus.     All  the  muscles  of  both  legs  are  some- 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  115 

times  paralysed  so  that  the  patient  is  compelled  to  walk  on  his 
knees,  dragging  his  small  thin  legs  after  him.  In  still  more 
aggravated  cases  the  muscles  of  both  legs  and  thighs  are  per- 
manently paralysed  so  that  the  small  flexible  limbs  dangle 
about  like  the  limbs  of  a  doll  (membre  de  polichinelle). 

Paralysis  of  the  muscles  of  the  trunk  does  not  give  rise  in 
this  disease  to  a  true  active  curvature  of  the  vertebral  column, 
but  the  attitudes  imposed  by  other  deformities  may  produce 
compensatory  curvatures.  Of  the  curvatures  directly  attributable 
to  the  paralysis,  lordosis  is  the  most  frequent  and  most  im- 
portant. Lordosis  is  caused  by  partial  paralysis  of  the  sacro- 
spinal muscles,  and  in  order  to  prevent  the  permanent  bending 
forwards  of  the  body  by  the  predominant  action  of  the  flexors, 
the  patient  voluntarily  throws  the  trunk  backwards,  thus  relieving 
the  weakened  extensors  and  throwing  additional  weight  on  the 
flexors,  so  that  the  balance  between  the  action  of  the  two  sets 
of  muscles  is  re-established.  The  spinal  curvature  which  results 
from  this  action  differs  from  other  forms  of  lordosis,  inasmuch 
as  the  pelvis  is  pushed  forwards  instead  of  backwards,  and  the 
buttocks  become  less  instead  of  more  prominent. 

The  deformities  of  the  upper  extremities  are  much  less 
frequent  and  serious  than  those  in  the  lower  extremities.  The 
muscles  of  the  shoulder,  and  particularly  the  deltoid,  are  the 
most  usual  subjects  of  paralysis  and  atrophy  in  the  upper 
extremity.  In  these  cases  the  shoulder  is  flattened,  and  the 
prominence  of  the  deltoid  is  replaced  by  a  more  or  less  deep 
depression  according  to  the  degree  of  atrophy;  the  humerus 
becomes  separated  from  the  glenoid  cavity,  so  that  dislocation 
may  occur  spontaneously,  or  is  readily  produced ;  the  arm  hangs 
powerless  by  the  side ;  and,  to  use  the  apt  comparison  of 
Heine,  dangles  about  like  the  loose  end  of  a  flail.  In  excep- 
tional cases  the  forearm  and  hand  may  undergo  distortion;  but 
these  deformities  are  not  of  sufiicient  importance  or  frequency 
to  require  description.  All  the  organic  functions  are  well  per- 
formed, and  the  patient  may  live  to  extreme  old  age,  as  in  the 
case  of  a  patient  observed  by  Charcot,  who  died  at  the  age  of 
seventy,  carrying  with  him  indelible  traces  of  the  disease  from 
which  he  had  suffered  sixty-five  years  before. 

The   muscles   are   paralysed  in  infantile  spinal  paralysis  in 


116  SYSTEM  DISEASES   OF  THE 

groups,  in  accordance  with  their  association  in  action.  Particular 
attention  has  recently  been  directed  to  this  point  by  E.  Remak. 
In  what  he  calls  "  the  upper-arm  type "  of  atrophic  paralysis, 
the  supinator  longus  is  involved  along  with  the  deltoid,  coraco- 
brachialis,  and  biceps  muscles.  In  what  Remak  calls  "  the 
forearm  type"  of  infantile  paralysis,  as  well  as  in  lead  paralysis, 
the  extensor  muscles  of  the  hand  are  paralysed,  while  the 
supinator  longus  is  spared. 

Analogous  facts  have  been  observed  in  the  various  atrophic 
paralyses  of  the  lower  extremities.  Cases  of  infantile  para- 
lysis are  recorded  by  E.  Remak  in  which  the  tibialis  anticus 
and  all  the  muscles  supplied  by  the  crural  nerve,  with  the 
exception  of  the  sartorius,  were  paralysed,  and  he  therefore 
conjectures  that  the  spinal  nuclei  of  the  former  and  those 
of  the  latter,  with  the  exception  of  that  of  the  branch  to 
the  sartorius,  lie  near  each  other  in  the  spinal  cord,  and  are 
liable  to  be  diseased  at  the  same  time.  Duchenne  has  proved 
that  the  sartorius  is  associated  in  its  functions,  not  so  much 
with  the  quadriceps  and  adductors,  as  with  the  flexors.  The 
sartorius  flexes  the  leg  on  the  thigh,  and  the  thigh  on  the  pelvis. 
Bernhardt  has  compared  the  sartorius  to  the  supinator  longus, 
and  it  appears  also  to  correspond  with  the  latter  in  having  its 
spinal  nucleus  near  that  of  the  flexors,  and  not  of  the  exten- 
sors with  which  it  is  in  anatomical  relation.  Cases,  however, 
have  not  yet  been  recorded  showing  that  the  sartorius  is  para- 
lysed along  with  the  flexors  of  the  leg,  the  extensors  being 
spared,  corresponding  to  what  occurs  with  the  supinator  longus 
in  the  upper-arm  type  of  atrophic  paralysis.  The  tibialis  anticus 
is  also  frequently  spared  in  infantile  paralysis  when, the  other 
anterior  muscles  of  the  leg  are  implicated.  Remak  states  that 
when  lead  paralysis  affects  the  lower  extremities  the  peroneal 
group  are  affected,  but  the  tibialis  anticus  is  spared,  and  he 
conjectures  that  the  spinal  nucleus  of  the  tibialis  anticus  is  on 
a  higher  level  than  those  of  the  other  muscles  of  the  peroneal 

region. 

(b)  Acute  Spinal  Paralysis  of  Adults. 

A-Cute  spinal  paralysis  of  adults  is  essentially  the  same 
disease  as  infantile  spinal  paralysis.  The  differences  between  the 
two  affections  result  from  the  facts  that  the  brain  of  the  adult 


SPINAL   COED  AND   MEDULLA  OBLONGATA.  117 

offers  greater  resistance  than  that  of  the  infant  to  the  initial 
disturbances  ;  that  the  organism  of  the  former  is  not  so  disposed 
to  fever ;  that  the  growth  of  the  bones  is  already  completed ; 
and  that  the  ligaments  and  joints  are  firm  and  resisting. 

The  disease  begins  in  the  adult  by  pain  in  the  back  and  the 
extremities,  parsestbesise,  such  as  formication  or  numbness,  and 
fever,  which  at  times  is  very  intense.  There  may  be  severe 
headache,  vomiting,  somnolency,  or  even  slight  delirium,  but 
convulsions  have  never  been  observed. 

The  paralysis  is  developed  more  or  less  rapidly,  generally  in 
the  course  of  a  few  hours,  and,  as  in  the  case  of  children,  it  is 
more  or  less  widely  spread,  complete,  and  associated  with  entire 
flaccidity  of  the  paralysed  muscles.  Reflex  action  is  either 
much  lowered  or  abolished  in  the  paralysed  muscles,  but  may 
be  retained  in  those  which  are  only  slightly  affected.  Tempo- 
rary weakness  of  the  bladder  may  be  present  at  first. 

The  initial  general  symptoms  pass  off  in  a  few  days,  soon 
afterwards  the  paralytic  symptoms  begin  to  improve,  and  after 
some  weeks  or  months  restitution  of  motor  power  may  be 
complete.  Frey  has  called  this  variety  temporary  paralysis, 
corresponding  to  the  form  of  the  same  name  in  children. 
Generally,  however,  there  is  only  partial  restoration  of  motor 
power,  some  of  the  muscles  remaining  permanently  paralysed. 
The  latter  muscles  undergo  rapidly  progressive  atrophy,  as  in 
the  case  of  children,  and  afford  the  usual  evidences  of  the 
reaction  of  degeneration.  The  skin  becomes  lax  and  withered 
and  the  extremities  cold  and  cyanotic. 

The  sensory  disturbances  which  may  have  existed  at  the 
beginning  soon  subside,  and  the  sensibility  becomes  normal, 
the  sexual  functions  are  throughout  unaffected,  there  are  no 
bed-sores,  and  the  general  health  is  good. 

Paralytic  contractions  supervene  with  their  resulting  deformi- 
ties, but  the  latter  never  attain  the  same  degree  as  in  children, 
because  the  joints  and  ligaments  are  firmer  in  the  adult,  and 
the  long  bones  of  the  extremities  have  attained  their  full 
development. 

§  397.  Course,  Duration,  and  Terminations. — The  ordinary 
course  of  the  disease  is  generally  the  same  as  that  already 


118 


SYSTEM  DISEASES   OF   THE 


described.  Cases  of  this  disease  divide  themselves  into  two 
classes  :  (1)  Those  in  which  complete  recovery  takes  place,  and 
(2)  those  in  which  the  recovery  remains  incomplete.  In  the 
first  variety  complete  restoration  of  all  the  muscles  takes  place 
in  the  course  of  a  few  weeks  or  months.  In  the  second  variety 
some  of  the  muscles  remain  permanently  paralysed,  and  atrophy, 
with  secondary  deformities,  results.  The  paralysis  does  not 
greatly  interfere  with  the  general  well-being  of  the  patient,  and 
does  not  appear  to  have  any  influence  in  accelerating  death,  at 
least  directly,  although  the  resulting  deformities  may  do  so 
indirectly.  Persons  who  have  had  an  attack  of  spinal  paralysis 
do  not  indeed  appear  to  be  more  liable  in  later  life  to  other 
affections  of  the  spinal  cord  than  healthy  persons  generally. 

§  898.  Morbid  Anatomy. — The  main  pathological  changes 
which  have  been  found  in  infantile  paralysis  may  be  sub- 
divided into  those  which  have  been  met  with  (1)  in  the  muscles, 
and  (2)  in  the  nervous  system.  Changes  have  been  found  in 
the  tendons  and  bones,  skin  and  joints,  but  these  are  of 
subordinate  importance. 

(1)  Morbid  Changes  in  the  Paralysed  Muscles. — It  is  quite 

Fig.  159. 


Fig.  159  (Young).  Muscular  Fibres  from,  a  case  of  advanced  Infantile  Paralysis, 
withdraion  hy  Leech's  trochar. — a,  Muscular  fibres  presenting  a  more  or  less 
healthy  appearance ;  b,  muscular  fibres,  somewhat  atrophied  and  with  granular 
contents ;  c,  muscular  fibres  greatly  atrophied,  but  presenting  faint  traces  of 
transverse  striation,  and  having  their  surfaces  thickly  studded  with  nuclei. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  119 

unnecessary  to  describe  at  length  the  changes  which  occur 
in  the  paralysed  muscles,  inasmuch  as  they  have  already  been 
described  in  the  first  part  of  this  work  (§  108),  along  with  the 
other  trophoneuroses.  By  the  kindness  of  Dr.  Leech,  I  am, 
however,  enabled  to  show  in  Fig.  159  the  condition  of  the 
muscular  fibres  in  advanced  atrophy  when  a  portion  of  the 
muscle  is  withdrawn  by  means  of  Leech's  trochar.  In  almost 
every  instance,  Dr.  Leech  assures  me  that  some  of  the  fibres 
appear  more  or  less  healthy  {a),  while  others  have  lost  their 
normal  striation,  their  contents  are  granular,  but  they  are  not 
much  diminished  in  size  (6).  A  large  number  are,  however, 
reduced  to  slender  and  transparent  fibres;  their  surfaces  are 
covered  by  nuclei;  the  transverse  striation  is  still  distinctly 
visible,  although  it  is  very  faint  {c).  At  times  two,  or  even 
three,  nuclei  may  be  seen  close  together,  suggesting  that  they 
have  been  derived  by  proliferation  from  one  nucleus  originally. 
The  nuclei  may  also  be  observed  to  project  distinctly  from  the 
surface  of  the  atrophied  fibre,  and  it  is  therefore  probable  that 
they  have  been  derived  either  from  the  nuclei  of  the  sarco- 
lemma  or  of  the  endomysium. 

(2)  Nervous  System. — The  lesions  which  have  been  found 
in  the  spinal  cord  are  undoubtedly  the  most  interesting  and 
mportant  of  all  those  which  have  been  observed  in  atrophic 
)aralysis.  For  a  long  time  theoretical  arguments  were  adduced 
01  the  one  hand  to  show  that  this  disease  was  a  nervous  affec- 
ton  either  of  spinal  or  peripheral  origin ;  while  on  the  other 
hind  it  was  maintained  that  the  seat  of  the  lesion  was  pri- 
narily  in  the  muscles,  and  hence  it  was  called  "  essential 
piralysis."  Heine  declared  in  favour  of  the  spinal  theory  of 
tlie  disease  in  1860,  in  the  second  edition  of  his  work.  This 
view  was  also  adopted  by  Duchenne,  but  it  was  not  confirmed 
by  post-mortem  examination  until  1864,  when  Cornil,  a  pupil  of 
Charcot,  first  recognised  distinct  alterations  in  the  spinal  cord, 
and  drew  special  attention  to  the  atrophy  of  the  anterior  grey 
horns.  Pre  vest  and  Vulpian,  however,  in  1866,  were  the  first 
to  make  the  positive  observation  that  the  essential  anatomical 
lesion  was  situated  in  the  grey  anterior  horn.  This  observation 
was  subsequently  confirmed  by  the  observations  of  Lockhart 
Clarke,  Charcot  and  Joffroy,  and  of  many  others. 


120  SYSTEM   DISEASES  OF  THE 

When  the  anatomical  basis  of  the  disease  was  once  established, 
it  soon  appeared  that  the  affection  was  not  exclusively  confined 
to  childhood.  Moritz  Meyer  was  the  first  to  point  out  that 
essentially  the  same  disease  was  met  with  in  adults,  and  this 
opinion  was  afterwards  confirmed  by  Duchenne.  Reports  of 
cases  have  recently  accumulated,  establishing  the  occurrence  of 
acute  atrophic  spinal  paralysis  in  adults  (Hallopeau,  Gombault, 
Bernhardt,  Frey,  Charcot,  Seguin,  Erb,  Weiss,  F.  Schultze, 
Sturge,  and  others). 

It  is  unnecessary  to  enter  into  a  minute  description  of  all  the 
published  reports  of  post-mortem  examinations  in  cases  of 
infantile  spinal  paralysis.  The  essential  anatomical  change  con- 
sists in  the  destruction  of  a  large  number  of  the  ganglion  cells 
of  the  anterior  horns,  and  this  lesion  is  the  cause  of  the  paralysis 
and  subsequent  atrophy.  The  lesion  is  generally  more  or  less 
difTused  through  the  anterior  grey  horns,  but  it  generally  reaches 
its  greatest  intensity  at  the  cervical  and  lumbar  enlargements, 
and  as  a  rule  leaves  no  permanent  alteration  except  at  these 
points.  It  may  extend  at  certain  points  somewhat  backwards 
towards  the  posterior  horns,  and  also  forwards  and  outwards  to 
the  antero-lateral  columns,  and  the  anterior  roots  of  the  nerves 
are  usually  atrophied,  but  these  are  secondary  changes  and  do 
not  appear  to  be  necessary  to  the  production  of  the  symptoms; 
The  observations  upon  which  this  conclusion  is  based  may  b< 
divided  into  those  which  have  been  observed  within  two  year) 
from  the  beginning  of  the  disease,  and  those  which  have  beel 
observed  after  long  intervals  of  time. 

Unfortunately  no  observations  have  yet  been  made  wilb 
respect  to  the  disease  during  the  first  few  days  or  weeks,  owing  \o  ' 
the  fact  that  the  disease  of  itself  is  not  fatal.  Dr.  Clifford  Allbutt 
reports  the  case  of  an  infant  seven  months  old  who  was  sud- 
denly paralysed  in  all  the  extremities.  Death  resulted  in  a 
short  time  from  implication  of  the  respiratory  nerves.  On 
post-mortem  examination  two  hsemorrhagic  clots  were  dis- 
covered in  the  cervical  region,  one  of  small  size  being  situated 
in  the  left  posterior  horn,  the  other  being  larger  and  situated 
in  the  right  posterior  horn  and  lateral  column.  Dr.  Allbutt 
thinks  that  if  these  lesions  had  been  found  in  the  lower  dorsal 
region  the  infant  would  probably  have  survived,  and  the  case 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  321 

might  have  been  regarded  as  one  of  infantile  spinal  paralysis. 
It  is,  however,  much  more  probable  that  this  was  a  case  of 
hgematomyelia.       An    instructive    case    is    reported    by    Dr. 
Charlewood  Turner  in  the  Pathological  Transactions  for  1879. 
A  child  two  and  a  half  years  of  age  fell  on  her  back,  but  played 
about  as  usual  for  a  fortnight  afterwards,  and  then  became 
suddenly  paralysed  in  her  lower  extremities,  and  in  a  few  days 
afterwards  in  her  upper  extremities  likewise.     On  admission  to 
the  London  Hospital,  a  fortnight  after  the  beginning  of  the 
attack,  all  the  extremities  were  completely  paralysed,  reflex 
action   in   them    was    also    abolished,    there   was   absence   of 
sensation  in  the  lower  extremities,  and  the  stools  were  passed 
involuntarily.     The  child  had  an  attack  of  measles,  and  died 
about  six  weeks  after  the  commencement  of  the  paralysis.     On 
post-mortem  examination,  which  was  made  by  Mr.  R.  W.  Parker, 
changes  were  observed  in  the  anterior  horns  and  antero-lateral 
columns  throughout  the  whole  length  of  the  cord,  these  being 
more  pronounced  on  the  left  than  the  right  side.     A  patch  of 
reddened  gelatinous-looking  matter,  about  the  size  of  a  swan 
shot,  was  observed  in  the  left  anterior  grey  horn  about  the  centre 
of  the  lumbar  enlargement.     The  margin  of  the  patch  was  of  a 
darker  colour  than  the  centre,  "as  from  the  decolorisation  of  an 
hsemorrhagic  extravasation."      In  the  neighbourhood   of  this 
hgemorrhagic  focus  the  nervous  tissues  were  completely  disin- 
tegrated,  so   that  no   nerve   structure  could  be  distinguished 
in  the  anterior  grey  horn,  the  outer  part  of  the  base  of  the 
posterior  cornua.      The  whole  grey  substance  was  abundantly 
infiltrated  with  leucocytes,  a  considerable  number  of  them  being 
also  observed  in  the  white  substance  ;  while  they  were  massed 
in  great  numbers  in  the  sheaths  of  the  larger  arterioles.     The 
vesicular  column  of  Clarke  did  not  appear  to  have  been  any- 
where affected.     In  the  portions  of  the  cord  which  were  remote 
from  the  seat  of  hsemorrhage,  the  nervous  structure  was  not 
completely  destroyed,  although  many  other  evidences  of  disease 
were  observed.    This  case  tends  to  confirm  Dr.  Allbutt's  theory 
of  the  origin  of  the  disease.    It  is,  indeed,  quite  probable  that  a 
small  haemorrhage  into  the  substance  of  the  anterior  horn  may 
sometimes  be  the  starting  point  of  the  affection. 

In  the  Pathological  Transactions  for  1879  the  case  of  a  child 


122 


SYSTEM  DISEASES   OF  THE 


three  and  a  half  years  of  age,  who  had  suffered  from  an  attack 
of  infantile  paralysis  at  the  age  of  seventeen  months,  is  reported 
by  Dr.  Henry  Humphreys,  On  admission  to  the  Pendlebury 
Hospital  the  child  presented  well-marked  talipes  calcaneus  of 
the  left  heel.  Soon  after  admission  the  patient  developed  a 
severe  attack  of  scarlet  fever,  from  which  she  died.  The  changes 
observed  by  Dr.  Humphreys  in  the  spinal  cord  were  limited 
to  the  lumbar  region,  and  consisted  mainly  of  a  remarkable 
diminution  in  the  number  of  the  ganglion  cells  belonging  to 
the  anterior  and  lateral  parts  of  the  left  anterior  grey  horn. 
The  annexed  diagram  {Fig.  160)  shows  the  condition  of  the 
anterior  cornua  at  the  middle  of  the  lumbar  region.  Dr. 
Humphreys  examined  eighty-seven  sections  of  the  lumbar 
region  of  the  cord,  and  averaged  the  number  of  cells  they 
contained. 

The  other  most  notable  cases  which  have  been  reported 
at  an  early  period  of  the  disease  are  those  of  Roger  and 
Damaschino,  Eoth,  Leyden's  second  case,  Parrot  and  Joffroy,  and 
a  case  briefly  reported  by  Rinecker,  which  was  examined  by  Von 
Recklinghausen.     No  marked  changes  were  discovered  in  the 


Fig.  160  (After  Humphreys).  The  letters  a,  h,  c  indicate  respectively  the  central, 
antero-lateral,  and  postero-lateral  groups  of  ganglion  cells.  On  the  left  side 
the  group  6  has  almost  entirely  disappeared,  causing  a  marked  falling  in  of  the 
circumference  of  the  grey  matter.  The  groups  a  and  c  are  fairly  well  represented 
on  the  left  side,  but  the  cells  composing  them  are  not  so  numerous  as  on  the 
right.    The  internal  group  has  disappeared  from  both  sides. 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  123 

cord  with  the  naked  eye.  In  some  cases  the  substance  of  the 
cord  seemed  tougher  at  the  level  of  the  cervical  or  lumbar 
enlargements,  and  the  antero-lateral  column  on  the  side  affected 
appeared  atrophied  and  distorted.  On  transverse  section  the 
anterior  grey  horns  were  observed  to  be  more  or  less  discoloured, 
whitish  or  reddish,  sometimes  soft,  diffluent,  and  diminished 
in  volume.  The  anterior  roots  at  the  level  of  the  parts  mainly 
affected  were  found  grey,  translucent,  and  atrophied. 

On  microscopical  examination,  the  main  lesions  hitherto 
observed  have  been  diffused  through  the  grey  substance  of  the 
anterior  horns  with  areas  of  greater  intensity  in  the  cervical  and 
lumbar  enlargements,  especially  in  the  latter.  In  the  lumbar 
region,  sometimes  on  one  side  only,  but  usually  on  both  sides,  an 
area  of  softening  has  been  found  in  the  anterior  grey  horn,  some- 
times extending  the  whole  length  of  the  lumbar  enlargement, 
and  sometimes  occupying  only  a  portion  of  it  in  longitudinal 
extent.  The  area  of  softening  was  sometimes  situated  towards 
the  centre,  sometimes  towards  the  anterior  part  of  the  horn, 
being  separated  from  the  surrounding  parts  by  a  more  or  less 
sharp  line  of  demarcation.  Similar  areas  were  often  also  found 
occasionally  in  the  cervical  enlargement  of  the  cord,  and  occa- 
sionally in  the  dorsal  and  upper  cervical  portions.  The  substance 
of  these  areas  was  friable,  soft,  and  disseminated  with  numerous 
granulation  cells.  The  blood-vessels  were  dilated,  there  was  a 
large  increase  of  connective  tissue,  and  the  nuclei  were  also 
increased  in  number.  Many  of  the  large  multipolar  ganglion 
cells  had  disappeared,  and  of  those  which  still  remained  a  large 
proportion  were  observed  in  all  stages  of  degeneration  and 
atrophy.  The  nerve  fibres  and  axis  cylinders  within  the  area 
of  softening  were  also  found  to  have  entirely  disappeared. 

Slighter  and  more  diffused  changes  occur  much  beyond  the 
limits  of  the  softened  areas.  These  changes  consist  of  single 
granular  cells  scattered  through  the  grey  substance,  multiplica- 
tion of  nuclei,  dilatation  of  blood-vessels,  and  disappearance  or 
degeneration  of  iudividual  ganglion  cells.  Similar  changes  are 
often  observed  throughout  a  greater  or  lesser  portion  of  the  grey 
substance  of  the  dorsal  region.  The  antero-lateral  columns  have 
occasionally  been  found  diminished  in  size,  and  the  seat  of  a 
slight  sclerosis.     The  trabeculse  are  then  thickened,  and  indi- 


124  SYSTEM  DISEASES  OF  THE 

vidual  nerve  fibres  are  atrophied  (Joffroy  and  Damaschino). 
The  anterior  roots  are  diminished  in  size,  and  show  signs  of 
degenerative  atrophy  when  examined  microscopically. 

Observations  have  been  made  from  seventeen  to  sixty-one 
years  after  the  origin  of  the  disease,  by  Cornil,  Provost  and 
David,  Vulpian,  Lockhart  Clarke,  Charcot  and  Joffroy,  Petit- 
fils  and  Pierret,  Leyden,  Gombault,  Ddjerine,  F.  Schultze,  and 
others. 

The  morbid  changes  which  have  been  observed  in  these  cases 
are  generally  the  same  as  in  those  which  have  been  examined 
within  two  years  of  the  onset  of  the  disease.  The  anterior  horns 
are  shrunk,  and  the  antero-lateral  columns  appear  to  the  naked 
eye  grey,  translucent,  and  atrophied.  The  posterior  columns, 
posterior  grey  horns,  and  vesicular  column  of  Clarke  are  almost, 
if  not  quite,  normal. 

On  microscopic  examination  circumscribed  lesions  are  found 
in  the  anterior  horns  at  the  lumbar  and  cervical  enlargements, 
and  in  addition  to  the  main  lesions  more  or  less  diffused  changes 
are  met  with  in  the  grey  substance  and  white  columns.  The 
anterior  horns  are  atrophied  and  shrunk,  and  within  the  diseased 
foci  which  they  contain  there  is  a  more  or  less  firm,  fibrillated 
connective  tissue,  rich  in  nuclei.  The  blood-vessels  are  enlarged, 
probably  also  increased  in  number,  and  their  walls  are  thickened. 
Granule  cells  are  generally  absent,  but  a  large  number  of  corpora 
amylacea  as  well  as  pigment  granules  have  been  found.  The 
multipolar  ganglion  cells  and  nerve  fibres  are  more  or  less  com- 
pletely destroyed  in  the  diseased  foci,  and  some  of  the  ganglion 
cells  which  remain  are  found  in  all  stages  of  degenerative  atrophy, 
pigmentary  degeneration,  and  shrivelling.  Well  preserved  gan- 
glion cells  may  be  found  outside  the  diseased  foci. 

In  the  portions  of  the  grey  cornua  which  are  comparatively 
healthy,  such  as  the  dorsal  region,  the  ganglion  cells  are  less 
numerous  than  normal,  the  connective  tissue  is  increased,  and 
the  nuclei  are  abundant. 

A  greater  or  lesser  degree  of  sclerosis  of  the  antero-lateral 
columns  may  be  discovered,  the  neuroglia  is  thickened,  and 
generally  there  is  some  degree  of  atrophy  of  the  nerve  fibres. 
The  sclerosis  may  vary  greatly  in  extent.  It  is  sometimes 
confined  to  the  immediate  vicinity  of  the  anterior  horns,  and  at 


SPINAL   CORD  AND   MEDULLA   OBLONGATA. 


125 


other  times  it  is  diffused  over  the  entire  antero-lateral  columns, 
the  pyramidal  tract  being  specially  liable  to  suffer. 


FlQ.  161  (From  Charcots  Transverse  Section  of  the  Spinal  Cord  taken  from  the  cer- 
vical region  of  a  woman,  aged  fifty  years,  who  died  in  the  Salpetriere,  of 
general  paralysis  of  the  insane,  and  who  was  the  subject  of  infantile  spinal 
paralysis  of  the  right  superior  extremity.  There  was  fibroid  atrophy  of  the 
right  anterior  cornu,  and  atrophy  of  all  the  white  columns  of  the  corresponding 
side. 

The  annexed  diagram  {Fig.  161)  well  illustrates  the  morbid 
alterations  which  are  usually  observed.  The  anterior  roots  are 
thin,  grey,  translucent,  and  the  greater  part  of  their  nerve 
fibres  are  atrophied,  the  connective  tissue  is  often  infiltrated 
with  fat  cells,  its  nuclei  are  abundant,  and  the  walls  of  the 
vessels  are  thickened.  Almost  all  pathologists  now  regard 
the  primary  lesion  as  an  inflammation  of  the  anterior  grey 
horns,  although  the  cases  reported  by  Drs.  Clifford  Allbutt  and 
C.  Turner  appear  to  show  that  a  slight  hemorrhage  ioto  the  grey 
substance  may  occasionally  be  the  starting  point  of  the  morbid 
process.  The  inflammatory  process  spreads  along  more  or  less 
diffusely  over  the  greater  part  of  the  anterior  horns,  but  attains 
its  greatest  intensity  in  the  lumbar  and  cervical  enlargements, 
in  which  localities  distinct  areas  of  softening,  and  destruction 
of  the  multipolar  ganglion  cells  are  produced. 


126  SYSTEM  DISEASES   OF   THE 

When  the  inflammation  subsides,  a  gradual  improvement 
takes  place  in  those  places  where  the  destruction  of  the  grey 
substance  has  been  incomplete  ;  but  where  the  nerve  structure 
has  been  thoroughly  disintegrated  there  is  a  gradual  develop- 
ment of  cicatricial  connective  tissue  in  its  place.  The  antero- 
lateral columns  become  secondarily  affected,  and  when  the 
lesion  takes  place  during  childhood  they  become  retarded  in 
their  development,  appear  narrow  and  atrophied,  and  cause  a 
considerable  change  in  the  form  of  the  spinal  cord. 

Whether  this  affection  is  to  be  regarded  as  a  parenchymatous 
or  an  interstitial  affection  is  not  yet  settled.  Charcot  and 
others  support  the  former  view ;  while  Roger  and  Damaschino, 
Roth  and  others,  are  in  favour  of  the  latter.  Dujardin- 
Beaumetz,  however,  suggests  that  both  tissues  become  in- 
flamed at  the  same  time,  and  that  the  myelitis  is  both 
parenchymatous  and  interstitial. 

The  peripheral  nerves  undergo  degenerative  atrophy,  F. 
Schultze  found  increase  of  the  interstitial  connective  tissue, 
with  atrophy  of  the  nerve  fibres. 

The  tendons,  atrophied  and  stretched,  appear  as  thin,  narrow 
bands. 

The  hones  are  always  retarded  in  growth  when  the  disease 
occurs  in  childhood,  the  normal  protuberances  and  processes 
being  less  developed,  and  their  epiphyses  stunted.  The 
medullary  portion  is  relatively  increased,  its  fatty  contents  are 
more  abundant,  and  the  external  hard  lamella  of  the  bone  is 
thin  and  friable. 

The  ligaments  of  the  joints  are  thin  and  loose,  while  the 
articular  extremities  of  the  bones  are  stunted,  ground  off, 
eroded,  and  their  cartilages  attenuated.  The  alterations  in 
the  joints,  ligaments,  and  articular  cartilages  greatly  aid  the 
muscular  paralysis  in  the  production  of  the  different  forms  of 
club-foot,  and  the  various  other  deformities  already  described. 

The  arteries  are  slightly  diminished  in  calibre,  the  skin  and 
internal  organs  are  either  normal  or  only  show  changes  which 
have  no  necessary  connection  with  the  spinal  disease.  The 
brain  is  normal.  In  one  case  Sander  found  the  two  ascending 
convolutions  and  the  paracentral  lobule — the  motor  area  of 
the  cortex   in  relation   with   the   paralysed   parts— relatively 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  127 

diminished  in  size,  but  as  the  spinal  disease  was  associated 
with  idiocy,  the  connection  between  the  atrophy  of  the  cortex 
and  the  spinal  lesion  may  have  been  merely  accidental.  Par- 
ticular attention  should  be  paid  to  the  condition  of  the  cortex 
in  future  post-mortem  examinations  in  cases  of  the  disease. 

§  399.  Localisation  of  the  Lesion  in  the  Anterior  Horns. 

A  very  interesting  case  in  this  reference  is  described  by  Prdvost  and 
David.*  It  was  that  of  a  man,  aged  sixty  years,  who  suffered  from 
febrile  and  typhoid  symptoms,  which  caused  his  death.  The  man  had 
complete  atrophy  of  the  muscles  of  the  thenar  eminence  of  the  right  hand, 
which  according  to  his  own  account  came  on  in  childhood.  The  anterior 
root  of  the  eighth  cervical  nerve  of  the  right  side  was  notably  diminished 
in  size,  as  compared  with  that  of  the  left  side,  and  the  anterior  root  of  the 
seventh  nerve  was  also  slightly  diminished  in  volume  on  the  right  side. 
Opposite  the  atrophied  root  of  the  eighth  nerve  the  anterior  horn  on  the 
same  side  was  observed  to  be  sensibly  diminished  as  compared  with  that  of 
the  left.  The  diseased  portion  had  a  longitudinal  extent  of  about  two 
centimetres,  and  the  centre  of  the  lesion  was  on  a  level  with  the  atrophied 
root.  Its  greatest  transverse  extent  was  also  opposite  the  diseased  root  of 
the  nerve  and  it  gradually  diminished  in  size,  both  upwards  and  downwards. 
The  author  says  that  in  the  diseased  portions  the  external  or  lateral  (postero- 
lateral) group  were  represented  by  a  few  healthy  cells,  while  the  anterior 
(antero-lateral)  and  the  middle  or  internal  (internal)  groups  were  normal. 
Judging  from  the  drawing,  however,  the  median  and  central  groups 
were  entirely  destitute  of  cells,  while  the  antero-lateral  group  was  only 
represented  by  one  cell. 

t  A  case  has  recently  been  described  by  Kahler  and  Pick  which  appears 
to  determine  the  localisation,  in  the  anterior  horns,  of  the  spinal  centres 
for  the  muscles  of  the  calf  of  the  leg.  The  case  was  that  of  a  woman, 
twenty-four  years  of  age,  who  died  from  an  attack  of  typhoid  fever.  The 
muscles  of  the  calf  of  the  right  leg  were  found  almost  completely  atrophied. 
On  examination  of  the  spinal  cord  the  right  anterior  grey  horn  was  found 
atrophied  through  the  greater  portion  of  the  lumbar  enlargement,  but  the 
most  marked  changes  were  observed  on  a  level  with  the  fourth  and  fifth 
sacral  nerves.  The  roots  of  these  nerves  were  also  atrophied,  there  was  a 
slight  increase  of  the  interstitial  connective  tissue,  which  was  especially 
well  marked  in  some  bundles.  The  central  group  of  cells  was  mainly 
affected. 

J  In  a  case  of  atrophic  spinal  paralysis  of  adults,  observed  by  Schultze 
in  a  man  aged  forty-two  years,  the  muscles  in  the  regions  of  distri- 

*  Archiv.  de  Physiologie,  Serie  II.,  Tome  i.,  1874,  p.  595. 

t  Archiv.  fur  Psychiatrie,  Bd.  x.,  2  Heft,  1880,  s.  358. 

tVirchow's  Archiv.,  Bd.  Ixxii.,  1878,  s.  443. 


128  SYSTEM  DISEASES   OF  THE 

bution  of  the  sciatic  nerve  in  both  legs  were  completely  paralysed, 
while  those  supplied  by  the  obturator  and  crural  nerves  were  spared. 
Schultze  found  sclerosis  of  both  anterior  horns  over  the  whole  of  the 
lower  half  of  the  lumbar  region,  and  he  consequently  concluded  that  the 
crural  and  obturator  nerve  nuclei  do  not  lie  in  the  lower  half  of  the  lumbar 
region  of  the  cord.  Remak,  however,  thinks  that  the  tibiales  antici  were 
also  spared  in  this  case,  and  placed  the  nuclei  of  these  muscles  in  the 
upper  half  of  the  lumbar  region  of  the  cord. 

The  condition  of  the  upper  extremity  in  Schultze's  case  was  no  less 
interesting.  The  muscles  of  the  back  from  the  sixth  dorsal  vertebra  down- 
wards were  yellow  and  atrophied.  The  shoulder  muscles  and  the  rhom- 
boids of  the  left  side  were  atrophied,  and  the  left  trapezius  was  degenerated 
to  a  less  degree,  the  left  deltoid  was  completely  degenerated,  the  supi- 
nator longus  of  the  left  arm  was  considerably  altered,  while  the  biceps  and 
triceps  were  said  to  have  been  normal,  and  the  coraco-brachialis  was  not 
mentioned.  On  examination  of  the  spinal  cord  the  left  anterior  horn,  in 
the  upper  segment  of  the  cervical  enlargement,  was  smaller  than  the  right, 
and  appeared  to  be  reduced  to  one-third  of  its  volume.  A  red  circum- 
scribed spot  was  observed  occupying  the  lateral  part  of  the  anterior  horn 
(postero-lateral  group).  The  condition  of  the  dorsal  region  of  the  cord 
is  not  mentioned,  but  so  far  as  the  case  goes  it  supports  the  idea  that  the 
muscles  of  the  scapula  and  shoulder  are  mainly  innervated  from  the 
postero-lateral  group. 

A  case  of  extreme  muscular  atrophy  is  reported  by  Dr.  Zach.  Johnson, 
which  was  evidently  an  example  of  infantile  paralysis,  and  in  which  "the 
muscles  of  the  shoulder  and  arm  had  altogether  disappeared.  The  muscles 
of  the  forearm  remained  apparently  unaffected.  The  muscles  of  the  ball 
of  each  thumb  were  almost  altogether  gone,  while  the  muscles  of  the 
fingers  continued  to  be  well  developed.  The  muscles  on  the  dorsum  of 
each  scapula  were  nearly  gone  also."*  The  lower  third  of  the  cervical 
enlargement  was  alone  sent  to  Dr.  Lockhart  Clarke  for  examination,  which 
is  a  source  of  quite  as  much  regret  to  others  as  it  was  to  Dr.  Clarke  him- 
self. An  examination  of  the  careful  drawings  made  by  Dr.  Clarke,  as 
well  as  of  his  description,  shows  that  the  weight  of  the  disease  falls  upon 
the  central  portion  of  the  grey  substance  along  the  distribution  of  the 
median  branch  of  the  central  artery,  and  that  the  postero-lateral  group  of 
cells  was  the  one  which  was  principally  injured.  This  case,  then,  so  far 
as  it  goes,  supports  the  opinion  already  advanced,  that  the  muscles  about 
the  scapula  and  shoulder-joint  are  innervated  from  the  postero-lateral 
group  of  cells  in  the  cervical  region.  But  in  this  case  "  the  muscles  of 
the  ball  of  each  thumb  were  almost  gone."  Are  we  to  believe  that 
they  also  are  innervated  from  the  postero-lateral  group  ?  The  case 
alone  certainly  does  not  prove  it.  Indeed  one  of  the  illustrations 
shows  distinctly  that  on  one  side  the  disease  had  spread  forwards  into 
the  area  of  distribution  of  the  anterior  branch  of  the  central  artery, 

*  Medico-Chirurgical  Transactions,  voL  li.,  1868,  p.  249. 


SPINAL   COED  AND   MEDULLA   OBLONGATA.  129 

and  consequently  amongst  the  median  group  of  small  cells,  while  Dr. 
Clarke  makes  special  mention  of  a  streak  of  disintegrated  tissue  which 
extended  backward  along  the  middle  of  the  posterior  horns  and  hence  in 
the  area  of  distribution  of  the  posterior  branch  of  the  central  artery. 
There  is  nothing  in  this  case,  therefore,  to  contradict  the  opinion  that  the 
muscles  of  the  ball  of  the  thumb  are  innervated  from  the  median  area. 

§  400.  Morbid  Physiology. — Infantile  spinal  paralysis  is  one 
of  the  diseases  the  morbid  anatomy  of  which  largely  contri- 
buted to  clear  up  our  knowledge  of  the  functions  of  the  grey 
anterior  horns.  The  multipolar  cells  probably  constitute  gan- 
glionic centres,  both  for  reflex  action  and  for  the  transmission  of 
impulses  received  through  the  pyramidal  tracts,  and  when  they 
are  destroyed  both  reflex  and  voluntary  actions  are  impaired  or 
abolished  according  as  the  destruction  of  the  cells  is  complete 
or  incomplete.  Destruction  of  these  cells  is  also  followed,  as 
we  have  seen,  by  various  trophic  changes  in  the  muscles,  bones, 
tendons,  and  joints. 

As  already  mentioned,  I  believe  that  the  ganglion  cells  of  the 
anterior  grey  horns  which  constitute  the  spinal  centre  for  the 
regulation  of  the  movements  of  a  muscle  also  constitute  for  it  a 
trophic  centre.  Most  muscles  are,  however,  connected  with 
fundamental  and  accessory  ganglion  cells,  and  it  is  only  when 
the  connection  between  the  former  and  the  muscle  is  severed 
that  profound  effects  both  upon  its  motor  power  and  nutrition  are 
produced.  The  acute  nature  of  the  lesion  in  infantile  paralysis, 
as  well  as  its  localisation,  is  well  adapted  to  sever  the  muscles 
from  their  connection  with  the  fundamental  cells,  even  if  the 
latter  were  to  remain  themselves  entirely  unaffected.  In  a  case 
observed  by  Charcot,  for  instance  {Fig.  162),  the  lesion  occupied  a 
position  in  which  only  a  few  of  the  fundamental  cells  would  be 
injured,  yet  a  large  number  of  fibres,  as  they  converge  to  pass 
out  to  the  anterior  roots,  must  have  been  destroyed,  and  the 
effect  would  consequently  be  very  similar  to  that  which  would 
follow  a  peripheral  lesion  of  the  nerve.  The  similarities  be- 
tween the  clinical  phenomena  of  infantile  spinal  paralysis  and 
peripheral  disease  of  the  nerves  are  too  obvious  to  require 
pointing  out.  The  case  is  wholly  different  when  we  have  to  do 
with  a  chronic  and  gradually  progressive  affection  like  pro- 
gressive muscular  atrophy,  in  which  the  accessory  cells  are  first 
J 


130 


SYSTEM  DISEASES  OF   THE 


attacked,  and  the  disease  by  slow  and  successive  steps  gradually 
invades  the  more  fundamental  cells.  In  such  a  disease  we  may 
expect  that  the  clinical  symptoms  of  paralysis  and  atrophy  will 
pursue  a  totally  different  course  from  that  which  obtains  in 
infantile  spinal  paralysis. 

Fig.  162. 


^)^i^ 

--j!.'.'         ■ 


Tig.  162  (From  Charcot).  Section  of  the  Spinal  Cord  in  the  Lumbar  Region,  from 
a  case  of  infantile  paralysis. — A,  Left  anterior  cornu,  healthy;  a.  Healthy 
median  group  of  ganglion  cells.  B,  Eight  anterior  cornu ;  b,  Median  group 
of  ganglion  cells.  The  cells  are  destroyed,  and  the  group  is  represented  by  a 
patch  of  sclerosis. 


The  fact  that  the  disease  occurs  in  certain  circumscribed 
areas  explains  the  distribution  and  extent  of  the  paralysis,  and 
the  immunity  of  certain  muscles  and  groups  of  muscles.  The 
acute  inflammatory  nature  of  the  process  explains  the  sudden 
appearance  of  the  paralysis  as  well  as  the  fever  and  other 
violent  symptoms  which  occur  at  the  onset  of  the  disease. 
The  resolution  of  the  acute  inflammation,  in  part  or  in  whole, 
explains  the  rapid  disappearance  of  the  first  severe  symptoms 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  131 

and  the  partial  or  complete  restitution  of  the  paral3'sed  muscles, 
which  afterwards  takes  place. 

§  401.  Diagnosis. — The  symptoms  of  acute  anterior  polio- 
myelitis are  so  definite  and  characteristic  that  it  is  not  easy  to 
confound  it  with  any  other  disease.  We  must,  however,  be 
careful  not  to  regard,  as  true  instances  of  this  affection,  every 
case  of  spinal  paralysis  which  arises  in  childhood,  even  if  ac- 
companied with  atrophy. 

Hcematomyelia,  or  hsemorrhage  into  the  grey  substance,  say 
of  the  lumbar  region,  may  produce  sudden  paralysis,  which  is 
followed  by  muscular  atrophy,  loss  of  reflex  excitability,  and  the 
reaction  of  degeneration  in  the  related  parts ;  but  the  initial 
fever  is  absent,  the  invasion  is  more  sudden  even  than  that  of 
infantile  spinal  paralysis,  the  former  being  almost  apoplectiform 
in  its  onset,  and  disturbances  of  sensibility,  paralysis  of  the 
sphincters,  and  bed-sores  are  present. 

In  acute  central  or  transverse  myelitis,  cutaneous  anaesthesia, 
paralysis  of  the  sphincters,  and  bed-sores  are  almost  invariably 
present ;  while  reflex  excitability  is  increased  in  transverse 
myelitis,  and,  as  a  rule,  there  is  no  atrophy. 

In  myelitis  from  compression,  disturbances  of  sensibility, 
paralysis  of  the  bladder,  tremors  of  the  lower  extremities,  in- 
creased reflex  excitability,  severe  pains,  and  affections  of  the 
vertebral  column  are  present;  the  general  health  usually  suffers 
greatly,  but  there  is  no  muscular  atrophy. 

Fror}i  cerebral  hemiplegia  this  disease  may  be  distinguished 
by  the  different  commencement  of  the  former  disease,  by  the 
implication  of  the  facial  nerve,  and  by  the  circumstance  that 
in  cerebral  paralysis  there  is  no  muscular  atrophy,  that  the  elec- 
trical irritability  is  preserved,  that  the  bones  are  not  affected, 
and  that  there  is  increased  reflex  excitability  of  the  tendons. 

Progressive  muscular  atrophy  develops  slowly  and  gradually, 
and  the  wasting  of  the  muscular  tissue  precedes  the  paralysis, 
while  the  electrical  irritability  is  retained. 

Paralysis  following  obstetric  operations  is  observed  imme- 
diately after  birth,  the  initial  fever  is  absent,  the  seventh  nerve 
is  the  one  most  frequently  affected,  while  this  nerve  is  never 
permanently  affected  in  anterior  poliomyelitis.     When  the  ami 


132  SYSTEM   DISEASES   OF  THE 

has  been  paralysed  by  pressure  of  the  blades  of  the  forceps  on 
the  brachial  plexus,  anaesthesia  remains  with  the  paralysis. 

The  spasmodic  spinal  paralysis  of  children  may  be  readily 
distinguished  from  anterior  poliomyelitis  by  the  slow  and 
gradual  development  of  the  paresis,  which  rarely  goes  on  to 
complete  paralysis,  by  the  muscular  tension  and  contraction, 
the  increased  irritability  of  the  tendons,  and  by  the  absence  of 
atrophy  and  the  reaction  of  degeneration. 

AmyotTophic  lateral  sclerosis  begins  in  the  upper  extremities, 
which  become  more  or  less  paralysed  and  wasted,  while  the 
antagonists  of  the  paralysed  muscles  become  rigid  and  con- 
tracted; the  arm  is  held  tightly  to  the  body,  the  forearm  is 
flexed  and  pronated,  and  the  hands  and  fingers  are  strongly 
flexed.  The  initial  fever  is  absent,  and  the  subsequent  progress 
of  the  disease  totally  differs  from  that  of  anterior  poliomyelitis. 

The  peripheral  paralysis  of  single  groups  of  muscles  from 
pressure  on  their  nerves  by  tight  bandaging  or  other  causes  will 
be  distinguished  from  anterior  poliomyelitis  by  the  absence  of  the 
characteristic  initial  stage,  the  strict  limitation  of  the  paralysis 
to  the  area  of  distribution  of  a  single  nerve  trunk,  the  occurrence 
of  an  injury  to  the  nerve,  the  presence  of  disturbances  of  sensi- 
bility, and  the  rapid  recovery  which  generally  takes  place. 

§  402.  Prognosis. — Anterior  poliomyelitis  does  not  appear 
ever  directly  to  threaten  life ;  and  consequently,  so  far  as  life  is 
concerned,  the  prognosis  is  very  favourable.  Tt  is,  however, 
possible  that  some  of  the  children  who  die  from  convulsions 
may  be  suffering  from  the  initial  stage  of  this  affection,  although 
this  opinion  has  not  yet  been  confirmed  by  post-mortem 
examination. 

So  far  as  complete  recovery  is  concerned  the  prognosis  is  un- 
favourable. In  recent  cases,  therefore,  the  only  prognosis  we  are 
warranted  in  making  is,  that  recovery  will  take  place  to  a  very 
considerable  extent,  but  that  a  certain  amount  of  permanent 
paralysis,  with  atrophy  and  deformity,  is  likely  to  be  left 
behind.  The  electrical  reactions  of  the  paralysed  muscles  form 
a  valuable  aid  in  prognosis.  If  the  faradic  contractility  of 
certain  muscles  and  nerves  is  diminished  at  the  end  of  five 
days  and  abolished  during  the  course  of  the  second  week,  these 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  133 

will,  according  to  the  law  of  Duchenne,  remain  permanently 
paralysed  and  atrophied ;  and,  conversely,  when  it  is  not 
abolished  by  that  time,  the  muscles  will  regain  their  mobility, 
and  the  restoration  will  be  the  more  prompt  and  complete  the 
less  their  faradic  irritability  is  diminished.  After  the  second 
week  the  galvanic  current  may  be  usefully  employed  to  test 
the  probability  of  the  degree  of  recovery  which  may  be  ex- 
pected in  the  paralysed  muscles.  So  long  as  a  muscle,  or  even 
a  portion  of  the  muscle,  responds  in  the  slightest  degree  to 
either  current,  a  certain  degree  of  recovery  of  motor  power  may 
be  expected. 

The  muscles  that  do  not  recover  a  certain  amount  of  motor 
power  during  the  first  few.  months  seldom  recover  at  a  later 
period;  and  after  six  months  of  complete  paralysis  all  hope  of 
recovery  may  be  abandoned,  although  even  then  slight  and 
partial  improvement  may  occur  under  appropriate  treatment. 

The  usefulness  of  the  paralysed  limbs  may,  however,  be 
greatly  improved  by  means  of  orthopoedic  operations,  gymnas- 
tics, and  electrical  treatment.  The  prognosis  in  this  respect 
will  depend  upon  the  degree  and  extent  of  the  paralysis  and 
atrophy,  the  amount  of  deformity  already  present,  the  age  of 
the  patient,  and  the  duration  of  the  disease  at  the  beginning 
of  the  treatment. 

§  403.  Treatment. — The  treatment  may  be  subdivided  into 
that  which  is  appropriate  during  the  acute  initial  stage  and  that 
which  is  to  be  adopted  during  the  subsequent  stages  of  paralysis, 
atrophy,  and  deformity.  During  the  initial  stage,  when  fever 
is  present,  rest  in  bed  is  absolutely  necessary,  and  leeches  may 
be  applied  over  the  lumbar  and  cervical  enlargements.  Rubbing 
in  of  mercurial  ointment  and  counter-irritation  by  means  of 
tincture  of  iodine  and  blisters  have  been  recommended,  but 
these  measures  should  certainly  not  be  adopted  until  the 
temperature  has  fallen  to  the  normal  standard.  Ergotine  has 
been  employed  subcutaneously  in  doses  of  one-fourth  of  a  grain 
for  a  child  from  one  to  two  years  of  age,  one-third  of  a  grain 
for  one  from  three  to  five  years,  half  a  grain  for  children  from 
five  to  ten  years  of  age,  and  a  grain  for  patients  upwards  of  ten 
years  of  age,  repeated  either  daily  or  twice  a  day,  according  to 


134  SYSTEM  DISEASES   OF  THE 

the  severity  of  the  symptoms  as  tested  by  the  degree  of  fever 
(Althaus).  Belladonna  has  been  employed  with  apparent 
benefit  in  this  stage  of  the  affection.  Iodide  of  potassium 
has  also  been  administered,  but  it  is  a  more  appropriate 
remedy  when  the  thermometer  indicates  that  the  fever  has 
subsided,  and  it  is  then  that  mercurial  inunction  and  counter 
irritation  can  be  employed  with  benefit.  For  my  own  part  I 
should  trust  during  the  feverish  stage  to  the  application  of  ice 
along  the  spine,  or  the  employment  of  Priessnitz's  cold  com- 
presses about  the  trunk,  and  frequently  repeated  small  doses  of 
aconite,  given  internally;  and  when  the  fever  had  subsided 
I  would  then  give  iodide  of  potassium  internally,  and  use  mild 
counter  irritation  along  the  spine,  followed  by  the  application 
of  mercurial  inunction.  By  the  first  method  I  would  hope  to 
arrest  the  active  inflammatory  process  and  limit  its  extension, 
and  by  the  second  to  aid  the  removal  of  the  products  effused 
into  the  grey  substance  of  the  anterior  horns,  and  thus  promote 
recovery. 

Resolution  of  the  changes  within  the  cord  may  be  advanced 
by  everything  which  aids  the  nutrition  and  advances  the  tissue 
changes  of  the  body  generally.  A  very  nutritious  and  abun- 
dant diet  should  be  prescribed  with  prolonged  sojourn  in  the 
open  air ;  mountainous  or  sea  air  is  especially  useful.  The 
thermal  springs  of  Wildbad,  Teplitz,  or  Gastein  have  been 
specially  recommended. 

The  constant  galvanic  current  should  be  used  as  soon  as 
the  fever  has  subsided,  and  it  should  be  made  to  pass  through 
the  diseased  area  of  the  cord.  If  the  leg  alone  be  affected, 
the  current  should  be  directed  to  the  lumbar  enlargement ;  if 
an  arm  only  be  affected,  the  cervical  enlargement  must  be 
acted  upon ;  and  if  the  muscles  of  the  trunk  suffer  likewise,  the 
whole  dorsa]  region  of  the  cord  should  be  included  in  the  circuit. 
In  order  to  reach  the  cord,  it  is  better  to  place  one  pole  on  the 
spine,  and  to  apply  the  other  to  the  anterior  surface  of  the 
trunk.  The  electrodes  should  be  large,  the  one  placed  over 
the  back  being  large  enough  to  cover  the  entire  diseased  area 
(Erb) ;  the  force  of  the  current  should  be  gentle,  and  the  appli- 
cation continued  for  from  three  to  ten  minutes  according  to 
the  extent  of  the  lesion  (Althaus).    Erb  has  recommended  that 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  135 

the  current  be  sent  through  the  cord  first  in  one  direction  and 
then  in  another,  but  Althaus  prefers  the  action  of  the  positive 
pole  alone.  The  treatment  must  be  continued  for  a  long  time, 
and  afterwards  repeated  at  intervals  for  years. 

At  the  later  period  of  the  disease,  when  atrophy  of  the 
paralysed  muscles  has  set  in,  a  peripheral  application  of  the 
constant  current  and  faradisation  of  the  paralysed  nerves  and 
muscles  may  be  combined  with  the  application  of  the  current 
to  the  spine.  So  long  as  the  nerves  and  muscles  have  not 
entirely  lost  their  faradic  irritability,  local  application  of  the 
faradic  current  will  be  of  service.  The  constant  current,  how- 
ever, is  on  the  whole  superior  to  the  induced,  even  for  peri- 
pheral application,  since  in  the  majority  of  cases  it  is  the  only 
agent  which  will  produce  any  muscular  response.  Appropriate 
gymnastic  exercises  of  the  muscles,  shampooing  and  friction, 
with  or  without  stimulating  liniments,  may  be  employed  as 
adjuncts  to  the  electrical  treatment.  When  the  case  comes 
under  treatment,  six  months  or  longer  after  the  invasion  of  the 
disease,  iodide  of  potassium  is  useless,  and  greater  benefit  may 
be  expected  from  phosphorous  and  cod-liver  oil.  Arsenic  has 
also  been  highly  recommended  at  this  stage  of  the  disease. 
The  use  of  strychnia  has  been  advocated,  especially  in  the  form 
of  subcutaneous  injection,  but  I  have  never  seen  any  good 
results  from  its  employment,  although  I  have  seen  the  remedy 
pushed  to  an  almost  dangerous  degree.  A  strenuous  endeavour 
should  be  made  to  prevent  the  occurrence  of  contractures  and 
deformities.  A  great  deal  may  be  done  in  this  respect  by  means 
of  electrical  treatment,  gymnastics,  and  light  frictions.  In 
guarding  against  talipes  equinus,  Yolkmann  advises,  during 
the  earliest  stages  of  the  disease,  that,  when  the  patient  is  lying 
down,  the  foot  be  fastened  to  a  light  footboard  by  means  of 
a  flannel  bandage,  and  its  extremity  drawn  up  somewhat 
towards  the  leg.  Children  should  wear  stout  laced  boots,  with 
a  steel  shank  on  the  outer  or  inner  side,  or  with  the  sole  slightly 
thicker  on  one  side,  so  that  the  tendency  to  the  development  of 
talipes  varus  or  valgus  may  be  counteracted.  The  formation  of 
talipes  calcaneus  may  be  counteracted  by  supplementing  the 
defective  action  of  the  posterior  muscles  of  the  leg  with  a 
strong  indiarubber  band  or  ring,  which  passes  from  the  heel 


136  SYSTEM  DISEASES  OF  THE 

to  a  trough-like  fixture  that  is  applied  to  the  leg  just  below 
the  knee,  and  which  is  held  firmly  in  its  place  by  a  side-bar 
fastened  to  the  shoe.  In  the  severer  forms  tenotomy  and 
forcible  means  of  correction  must  be  adopted;  but  it  is  no  part 
of  this  work  to  enter  into  the  details  of  orthopoedic  surgery,  and 
the  reader  must,  therefore,  be  referred  to  special  works  for  the 
further  discussion  of  the  subject. 


2.  Poliomyelitis  Anterior  Chronica  {Chronic  Atrophic 
Spinal  Paralysis). 

§  404  Definition. — Chronic  atrophic  spinal  paralysis  of 
adults  presents  itself  as  a  motor  paralysis  associated  with 
muscular  atrophy,  which  begins  in  the  lower  extremities,  and 
gradually  progresses  upwards  until  the  muscles  of  the  trunk 
and  upward  extremities  are  involved.  The  affection  may 
terminate  in  death  from  respiratory  paralysis,  or  in  gradual 
recovery,  the  motor  power  returning  in  the  reverse  order  to 
that  in  which  it  was  lost. 

History. — Duchenne  first  described  this  affection  in  1849,  then  in 
1852,  and  he  gave  a  detailed  description  of  it  in  the  third  edition  of  his 
Electrization  Localisee  in  1872.  He  believed  on  theoretical  grounds  that 
the  disease  consisted  in  chronic  degeneration  of  the  grey  anterior  horns, 
and  consequently  he  designated  it  "  Paralysie  generale  spinale  anterieure 
subaigue."  Single  instances  of  the  disease  have  since  been  described  by 
various  authors,  such  as  Poche,  Frey,  Erb,  Webber,  Cornil  and  Lepine, 
Klose,  Goltdammer,  Bernhardt,  Aufrecht,  and  others. 

§  405.  Etiology. — The  causes  of  this  disease  are  exceedingly 
obscure.  All  the  cases  which  have  been  observed  occurred 
in  adults  between  the  ages  of  thirty  and  fifty  years. 

Amongst  the  exciting  causes  the  most  frequent  are  traumatic 
injuries,  such  as  a  fall  on  the  back  or  hip,  exposure  to  severe 
cold,  damp  dwellings,  and  alcoholic  and  sexual  excesses. 
Chronic  lead  poisoning  leads  to  a  condition  very  similar  to 
chronic  atrophic  spinal  paralysis. 

§  40G.  Symptoms. — The  first  symptoms  are  usually  lassitude 
and  fatigue  in  walking,  with  pain  and  stiffness  in  the  loins  and 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  137 

lower  extremities,  which  may  be  accompanied  by  slight  fever,  gas- 
tric disturbances,  and  headache.  The  patient  may  also  complain 
of  various  parsesthesise.  After  a  time  there  is  distinct  muscular 
weakness,  sometimes  only  in  one,  at  other  times  in  both  leg-^. 
The  muscular  weakness  gradually  increases,  the  movements  of 
the  ankle-joint  being  usually  more  interfered  with  than  those 
of  the  hip-joint.  After  a  time  the  paresis  increases  to  complete 
paralysis  of  single  muscles  and  groups  of  muscles,  or  of  the 
entire  extremity.  The  muscles  are  flaccid  and  soft,  and  no 
resistance  is  offered  to  passive  movements  of  the  paralysed 
extremities.  The  rapidity  with  which  the  paralysis  takes  place 
varies  greatly.  Sometimes  it  occurs  in  a  few  days,  sometimes 
not  till  after  the  lapse  of  many  months,  or  even  years. 

Soon  after  the  paralysis  is  established  the  affected  muscles 
begin  to  waste ;  the  calves  of  the  legs  become  converted  into 
loose,  flabby  sacks,  the  muscles  of  the  thigh  and  gluteal  region 
grow  thin  and  soft,  and  the  limbs  may  ultimately  be  reduced  to 
a  condition  in  which  the  skin  appears  to  rest  immediately  upon 
the  bones.  Fibrillary  twitchings  of  the  muscles  usually  accom- 
pany the  earlier  stages  of  atrophy.  Reflex  action,  both  cuta- 
neous and  tendinous,  is  completely  abolished  in  the  paralysed 
muscles. 

The  sensibility  of  the  skin  usually  remains  normal ;  but 
occasionally  the  patient  may  complain  of  a  slight  degree  of 
insensibility  and  numbness. 

The  paralysis  gradually  spreads  to  the  upper  extremities, 
their  movements  become  awkward  and  feeble,  and  complete 
paralysis  of  them  ultimately  supervenes.  All  the  muscles  of 
the  upper  extremities  are  not  simultaneously  affected;  at  times 
the  extensor  muscles  of  the  forearm  are  earlier  and  more 
severely  paralysed  than  the  rest;  at  other  times  the  flexors  and 
intrinsic  muscles  of  the  hand  are  the  first  to  be  attacked ;  and, 
as  a  rule,  the  fingers  and  hands  are  more  severely  paralysed 
than  the  forearm  and  shoulder.  The  hands  assume  characteristic 
positions,  and  the  arms  lie  flaccid  and  immovable  as  they  are 
placed.  Rapidly  progressive  atrophy  ensues,  which  leads  to  the 
highest  degrees  of  emaciation,  especially  in  the  hands  and  fore- 
arms. Reflex  action  is  generally  abolished  in  the  paralysed 
muscles,  sensation  is  normal,  but  the  patient  may  complain  of 


138  SYSTEM   DISEASES   OF   THE 

numbness  in  the  fingers,  and  of  parsesthesia  in  the  region  of 
distribution  of  the  ulnar  nerve. 

The  muscles  of  the  back  and  abdomen  are  occasionally 
implicated  ;  the  patients  can  no  longer  sit  up  ;  expiration, 
coughing,  sneezing,  and  defecation  are  rendered  difficult.  The 
bladder,  rectum,  and  sexual  organs  remain  entirely  unaf- 
fected. There  are  no  bed-sores,  and  the  general  health  is 
satisfactory. 

The  electrical  phenomena  in  the  paralysed  nerves  and 
muscles  are  the  same  as  in  acute  anterior  poliomyelitis,  only 
modified  slightly  in  correspondence  with  the  slower  develop- 
ment of  the  malady. 

Duchenne  showed  that  faradic  excitability  was  diminished 
at  an  early  period  of  the  paralysis,  and  was  soon  entirely  lost. 
In  a  case  observed  by  Erb  the  nerves  did  not  respond  either  to 
the  faradic  or  galvanic  currents,  and  the  muscles  manifested 
the  typical  reaction  of  degeneration. 

During  recovery  the  electrical  excitability  returns  to  the 
normal  standard  only  very  slowly  and  gradually.  The  further 
course  of  the  disease  is  somewhat  variable.  In  the  majority  of 
cases  the  paralytic  symptoms  remain  stationary  for  a  time; 
although  the  muscular  atrophy  may  continue  to  advance  to  some 
extent  and  moderate  "  paralytic  contractions  "  to  be  developed. 
After  some  weeks  or  months  gradual  improvement  sets  in,  which 
begins  in  the  arms  and  hands,  and  as  it  gradually  advances  from 
raascle  to  muscle  the  galvanic  excitability  of  the  muscles  sinks 
more  and  more,  and  slowly  gives  place  to  the  normal  reaction, 
while  the  contractures  also  gradually  disappear. 

Kecovery  is  so  slow  that  it  is  only  after  the  lapse  of  months 
that  the  patients  can  feed  themselves  and  perform  other  actions 
with  their  hands. 

The  improvement  extends  after  a  time  to  the  lower  ex- 
tremities, the  movements  of  the  hip-joint  first  becoming  more 
powerful  than  those  of  the  knee-joint,  and  last  of  all  those  of 
the  foot  and  toes,  until  ultimately  recovery  may  be  complete. 

More  frequently,  however,  the  recovery  is  incomplete.  Cer- 
tain sets  of  muscles,  especially  those  in  the  region  of  distribution 
of  the  peroneal  nerve,  remain  paralysed  and  wasted,  so  that  the 
patient  is  partially  disabled  for  life. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  139 

In  a  certain  small  number  of  cases  the  disease  progresses  up- 
wards to  the  medulla  oblongata,  when  articulation,  mastication, 
deglutition,  and  ultimately  respiration  are  interfered  with,  and 
the  patient  dies  from  asphyxia.  At  other  times  death  super- 
venes from  simple  exhaustion.  The  progressive  cases  terminate 
in  from  one  to  four  years,  and  the  favourable  cases  generally  last 
months  or  years. 

I  am  indebted  to  Mr.  E.  L.  Luckman,  one  of  the  House 
Physicians  to  the  Royal  Infirmary,  for  the  notes  of  the  following 
case  : — 

Eliza  R ,  aged  15  years,  entered  the  Royal  Infirmary  on  August 

23rd,  1880,  under  the  care  of  Dr.  Ross. 

History. — She  has  been  weakly  from  infancy,  and  has  worked  in  the 
mill  in  a  hot  room  since  she  was  eleven  years  of  age.  About  six  months 
ago  her  work  caused  her  an  unwonted  amount  of  fatigue,  and  she  soon 
afterwards  noticed  that  there  was  distinct  loss  of  power  in  the  left  leg  and 
arm,  followed  after  a  brief  interval  of  time  by  weakness  of  the  left  leg. 
The  weakness  of  the  lower  extremities  gradually  increased,  so  that  in  two 
months  from  the  commencement  of  the  attack  she  was  compelled  to  leave 
oflf  work.  She  states  that  she  has  been  unable  to  walk  for  the  last  three 
months,  but  it  was  found  that,  with  assistance,  she  could  make  a  few  steps, 
the  limbs  being,  as  it  were,  dragged  forward.  She  has  entire  control  over 
the  sphincters,  and  the  only  sensory  disturbances  complained  of  have 
been  "  springing"  pains  in  both  legs. 

Present  Condition.  — Ks,  she  lies  in  bed  she  has  a  suffering,  anxious 
expression,  and  the  muscles  of  the  trunk  and  extremities  are  seen  to  be 
much  wasted.  The  upper  lips  are  dry  and  cracked,  the  teeth  are  covered 
with  sordes,  and  the  tongue  has  a  beef-steak  appearance. 

Left  arm  lies  by  the  side,  the  elbow  being  removed  two  inches  from  the 
body.  The  left  forearm  is  flexed  at  right  angles  to  the  upper  arm  ;  it  is 
strongly  pronated,  so  that  the  ulnar  side  of  the  hand  is  directed  upwards. 
The  hand  is  slightly  extended  on  the  forearm,  the  first  phalanges  are  semi- 
flexed on  the  metacarpal  bones,  the  second  phalanges  are  semi-flexed  on 
the  first,  and  the  third  on  the  second.  The  muscles  of  the  ball  of  the 
thumb  are  decidedly  wasted,  and  those  of  the  hypothenar  eminence  are 
also  atrophied.  The  patient  cannot  produce  opposition  of  the  thumb, 
and  adduction  is  feeble.  The  metacarpal  bone  of  the  thumb  lies  on  a 
level  with  the  metacarpal  bone  of  the  index  finger.  The  first  phalanx  of 
the  thumb  is  extended,  and  slightly  abducted,  the  second  phalanx  being 
.slightly  flexed  on  the  first.  The  general  position  of  the  right  arm  corre- 
sponds to  that  of  the  left.  Abduction  of  the  thumb  is,  however,  much 
more  powerfully  performed  on  the  right  side  than  on  the  left  side,  the 
fingers  of  both  hands  are  in  a  semi-closed  position,  the  index  and  middle 
less  closed  than  the  ring  and  little  fingers.      The  interossei  are  atrophied, 


140  SYSTEM  DISEASES   OF   THE 

causing  deep  grooves  to  appear  between  the  metacarpal  bones.  All  the 
movements  of  the  different  segments  of  the  right  arm  can  be  performed, 
but  supination  of  the  forearm  is  very  feeble,  and  can  only  be  effected  to 
a  position  midway  between  pronation  and  supination.  The  left  hand  lies 
powerless,  in  the  position  already  described,  and  can  be  moved  only  to  a 
slight  extent. 

The  lower  extremities  are  almost  completely  paralysed,  and  when 
the  patient  is  asked  to  move  them  only  a  slight  movemect  occurs,  which 
is  effected  by  the  muscles  of  the  thigh.  The  anterior  muscles  of  the  calf 
are  quite  paralysed.  Both  feet  occupy  the  position  of  talipes  equinus; 
but  the  deformity  can  be  readily  made  to  disappear  by  producing 
passive  dorsal  flexion  of  the  foot.  The  different  segments  of  the  lower 
extremities  can  be  readily  moved  upon  one  another,  the  muscles  are 
flaccid,  and  there  is  a  complete  absence  of  the  quadriceps  tendo-reflex  and 
of  ankle  clonus.  There  are  no  tremors  or  fibrillary  contractions  of  the 
muscles  of  the  lower  extremity,  but  a  few  fibrillary  contractions  are 
occasionally  observed  in  the  left  hypothenar  eminence.  The  patient 
cannot  raise  herself  in  bed,  but  on  being  asked  to  do  so  the  recti  muscles 
of  the  abdomen  may  be  felt  to  contract  slightly,  but  have  not  sufficient 
power  to  raise  the  body.  With  the  exception  of  an  occasional  dribbling 
of  urine,  the  functions  of  the  bladder  and  rectum  are  normally  performed, 
and  the  abdominal  muscles  contract  slightly  during  the  acts  of  defecation 
and  urination.  When  she  is  raised  in  a  sitting  posture  she  cannot  hold 
the  body  erect. 

At  the  onset  of  the  attack  she  had  some  "springing"  pains  in  the 
lower  extremities,  but  these  abnormal  sensations  have  now  disappeared. 
She  can  distinguish  two  points  touching  the  surface  of  the  outer  side  of 
the  leg  when  two  inches  apart. 

The  sense  of  temperature  is  very  accurate  and  that  of  touch  good. 
Every  form  of  sensibility  is,  indeed,  perfectly  normal  all  over  the  body. 

The  reflex  of  the  sole  of  the  foot,  the  gluteal,  abdominal,  epigastric, 
and  scapular  reflexes  are  absent. 

The  faradic  contractility  of  the  affected  nerves  and  muscles  is  entirely 
abolished. 

The  galvanic  current,  applied  percutaneously,  obtains  no  response  from 
the  anterior  muscles  of  the  legs,  even  when  fifty  Leclanche  cells  are  used. 

On  the  current  being  applied  by  electric  acupuncture,  the  muscles  of 
the  anterior  part  of  the  leg  contract  slightly  with  fifteen  cells  on  cathodal 
closure,  but  do  not  contract  on  anodal. 

When  the  galvanic  current  is  now  applied  after  the  needles  have  been 
removed,  the  anterior  muscles  of  the  leg  contract  distinctly  on  cathodal 
closure  with  fifty  cells. 

The  extensors  of  the  right  forearm  contract  slightly  on  cathodal  closure 
with  fifty  Leclanche  cells,  but  give  no  reaction  on  anodal  closure. 

The  extensors  of  the  left  forearm  give  no  response  either  on  cathodal 
or  anodal  closure  or  opening  when  fifty  cells  are  used. 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  141 

The  treatment  consisted  of  the  stabile  application  of  the  constant 
current  to  the  spine  for  a  few  minutes  daily,  the  current  being  also  passed 
for  a  longer  period  daily  through  the  affected  nerves  and  muscles.  No 
sensible  alteration  took  place  in  her  condition  until  the  evening  of  Sep- 
tember 16th,  when  the  breathing  was  observed  to  be  embarrassed.  At 
three  o'clock  in  the  morning  the  hands  and  lips  were  livid;  the  eyes  were 
half  closed ;  her  face  and  body  were  bathed  in  cold  perspiration ;  the  voice 
was  weak ;  the  diaphragm  had  ceased  to  play,  respiration  consisting  chiefly 
of  an  elevation  movement,  and  could  not  be  made  to  contract  by  a  strong 
faradic  current  passed  through  the  phrenic  nerves.  She  seemed  to  rally 
a  little  for  a  short  time,  but  the  diaphragm  remained  paralysed. 

At  nine  a.m.,  September  17th,  the  surface  was  bathed  in  profuse  per- 
spiration ;  the  skin  was  cold  and  clammy,  the  temperature  being  97 '6; 
the  lips  and  hands  were  livid ;  and  the  pulse  was  feeble  and  quick,  beating 
152  in  the  minute ;  the  respirations  were  slow  and  ineffectual,  but  she 
remained  conscious  to  the  last,  and  died  at  eleven  a.m. 

Autopsy. — Immediatly  after  death  the  body  was  placed  face  downwards, 
the  spine  was  covered  with  ice  until  the  post-mortem,  conducted  by 
Dr.  Alfred  Young,  in  the  evening.  No  changes  worth  recording  were 
observed  by  the  naked  eye  in  the  brain,  or  even  in  the  spinal  cord.  The 
veins  over  the  posterior  surface  of  the  lumbar  region  of  the  cord  were 
greatly  distended.  On  making  transverse  sections  of  the  spinal  cord  at 
intervals  of  a  quarter  of  an  inch  from  above  downwards,  it  was  observed 
that  definite  areas  of  the  white  substance  were  of  a  grey  colour  and 
gelatinous  appearance.  The  grey  substance  of  the  central  columns  and 
anterior  horns  from  the  fifth  or  sixth  cervical  nerves  downwards  was 
depressed  below  the  white  substance  in  each  section,  and  appeared  of 
soft  consistence,  and  was  intersected  in  every  direction  by  dilated  and 
engorged  vessels. 

Microscopic  examination  showed  that  the  ganglion  cells  of  the  anterior 
grey  horns  had  almost  completely  disappeared  throughout  the  entire  length 
of  the  spinal  cord  {Fig.  163,  1  to  4).  The  central  column  and  anterior  horns 
were  intersected  with  dilated  blood-vessels,  the  walls  of  the  vessels  were 
thickened,  the  nuclei  of  the  neuroglia  were  greatly  increased  in  number, 
and  the  tissue  was  infiltrated  with  leucocytes.  In  some  sections  the  cells 
of  the  vesicular  column  of  Clarke  appeared  smaller  and  rounder  than 
normal,  but  on  the  whole  this  column  did  not  seem  to  be  much  affected 
with  disease.  The  posterior  grey  horns  appeared  normal  in  every  respect. 
The  upward  continuation  of  the  central  grey  column  in  the  medulla  oblon- 
gata {Fig.  163,  5)  presented  similar  morbid  appearances  to  those  observed 
in  the  grey  substance  of  the  spinal  cord,  and  the  cells  of  the  accessory 
nuclei,  as  well  as  those  of  the  nucleus  of  the  eleventh  nerve,  had 
disappeared ;  but  the  fundamental  cells  of  the  hypoglossal  nucleus,  instead 
of  beiug  destroyed,  were  hypertrophied.  A  few  hypertrophied  cells  were 
also  observed  in  some  sections  in  the  centres  of  the  internal  and  antero- 
lateral groups  in  the  cord,  especially  in  the  cervical  region,  while  others 


142 


^-x^ 


SYSTEM   DISEASES   OF   THE 


were  represented  by  small  angular  masses 
without  processes ;  but  all  the  accessory 
cells,  and,  indeed,  the  majority  of  the  funda- 
mental cells  in  the  cord,  had  disappeared 
without  a  trace  of  them  being  left. 

On  holding  a  section  from  the  middle 
of  the  dorsal  region  up  to  the  light,  a  patch, 
which  was  more  highly  coloured  by  carmine 
than  the  surrounding  tissue,  could  be  dis- 
tinctly observed  in  the  posterior  root-zone, 
where  it  adjoins  the  column  of  GoU.  It 
began  near  the  posterior  commissure,  and 
extended  backwards  towards,  although  it 
did  not  reach,  the  posterior  surface  of  the 
cord.  The  deeply-stained  portions  were 
symmetrically  placed  on  each  side  of  the 
columns  of  GoU,  and  to  the  naked  eye  they 
presented  all  the  characters  of  patches  of 
sclerosis  {Fig.  163 ,  2).  Similar  patches 
were  observed  in  the  cervical  region,  but 
they  were  more  diffused  than  those  in  the 
dorsal  region,  their  areas  were  larger,  and 
they  did  not  stain  so  deeply  with  carmine. 
In  many  sections  the  peripheral  layer  of 
the  cord  was  deeply  stained,  this  being 
especially  marked  in  the  anterior  root-zones 
and  columns  of  Tiirck.  When  the  deeply- 
stained  portions  were  examined  micro- 
scopically, the  connective-tissue  septa  were 
found  swollen,  a  few  of  the  nerve  fibres 
had  disappeared,  but  the  majority  of 
these  were  normal.  The  most  remarkable 
morbid  alteration,  however,  observed  was 
the  great  increase  in  the  number  of  Deiter's 
cells. 

A  large  number  of  the  nerve  fibres  of 
the  anterior  roots  had  undergone  atrophy, 


Fig.  163  (Young).  Transverse  Sections  of  the 
Spinal  and  Medulla  Oblongata  at  different 
levels,  from  a  case  of  chronic  atrophic  spinal 
paralysis,  showing  the  disappearance  of  the 
ganglion  cells. — 1,  Middle  of  the  lumbar 
enlargement ;  2,  Middle  of  the  dorsal  region ; 
o.  Middle  of  the  cervical  enlargement ;  4,  tiec- 
tion  on  a  level  with  the  origin  of  the  second 
cervical  nerve ;  5,  Section  of  the  medulla 
oblongata  on  a  level  with  the  middle  third  of 
the  olivary  body. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  143 

and  some  of  the  bundles  were  replaced  by  connective  tissue.     A  consider- 
able number  of  the  fibres,  however,  appeared  normal. 

Portions  of  the  anterior  muscles  of  the  leg,  and  of  those  of  the  hypo- 
theuar  emineuce,  were  subjected  to  microscopical  examination  by  Dr. 
Leech,  who  kindly  examined  those  muscles  for  me,  and  submitted  the  fol- 
lowing report : — 

"  On  transverse  section  the  muscular  fibres  are  seen  to  be  separated 
by  an  undue  amount  of  fibrous  tissue,  while  the  nuclei  of  the 
endomysium  are  greatly  increased  in  number.  The  fibres  themselves 
vary  in  diameter,  some  of  them  being  considerably  smaller  than  others, 
and  the  nuclei  beneath  the  sarcolemma  are  increased  in  number. 
Examination  of  longitudinal  sections  shows  that  the  muscle  corpuscles  are 
increased  in  number,  and  that  the  structure  of  the  muscular  fibre  is 
greatly  altered  in  other  respects.  Many  of  the  muscular  fibres  are 
granular,  their  transverse  striation  is  indistinct  or  wanting,  and  the 
muscle  corpuscles  are  increased  in  number.  The  most  remarkable  changes 
observed,  however,  consisted  in  an  alteration  of  the  normal  relation  of  the 
contractile  and  interstitial  discs.  The  contractile  discs  seemed  to  be 
shortened,  and  swelled  out  laterally.  In  consequence  of  this  change,  the 
interstitial  discs  appeared  as  transverse,  more  or  less  transparent,  bands 
between  the  darker  bars  formed  by  the  contractile  discs,  and  the  former 
being  also  narrower  than  the  latter,  the  outline  of  the  fibre  has  a  rugose 
or  serrated  appearance. 

"  Several  nuclei  are  sometimes  observed  in  the  transparent  bands, 
while  one  or  more  muscle  corpuscles  are  obscurely  seen  in  the  darker 
bars. 

"  It  is  doubtful  how  far  the  changes  just  described  are  the  result  of 
disease,  inasmuch  as  similar  appearances  may  sometimes  be  seen,  although 
never  to  the  same  extent,  in  healthy  muscle  withdrawn  during  life  by  the 
muscle  trocar  ;  and  the  autopsy  in  this  case  being  conducted  a  few  hours 
after  death,  the  muscle  would  have  been  placed  in  preservative  fluid  before 
post-mortem  rigidity  had  taken  place." 

A  case  of  chronic  atrophic  spinal  paralysis  has  recently  been 
described  by  Aufrecht,  in  which  a  post-mortem  examination 
had  been  obtained,  and  the  spinal  cord,  nerves,  and  muscles 
subjected  to  careful  microscopic  examination.  The  appearances 
observed  correspond  on  the  whole  pretty  closely  with  those  just 
described.  In  Aufrecht's  case,  however,  the  ganglion  cells  of 
the  anterior  horns  were  by  no  means  changed  to  anything  like  the 
same  extent  they  were  in  the  case  observed  by  me.  From  a 
careful  examination  of  Aufrecht's  description  of  the  morbid 
alterations  in  the  anterior  horns,  it  is  evident  to  me  that  the 
fundamental  cells  were  hypertrophied,  and«<4hat  some   of  the 


144  SYSTEM   DISEASES   OF   THE 

accessory  cells  were  shrivelled,  while  probably  a  considerable 
number  of  them  had  disappeared. 

§  407.  Diagnosis. — The  chronic  may  be  distinguished  from 
the  acute  form  of  anterior  poliomyelitis  by  the  slow  and  gradual 
manner  in  which  the  former  and  the  sudden  way  in  which  the 
latter  begins.  The  subacute  or  chronic  form  has  for  some  time 
a  progressive  course,  and  extends  more  or  less  gradually 
upwards,  and  the  disease  may  terminate  fatally  or  advance 
slowly  towards  recovery.  The  course  of  this  disease,  therefore, 
differs  greatly  from  that  of  the  acute  form. 

Progressive  muscular  atrophy  may  be  distinguished  from 
chronic  atrophic  spinal  paralysis  by  the  circumstance  that  in 
the  former  the  paralysis  and  atrophy  proceed  side  by  side, 
while  in  the  latter  the  paralysis  precedes  the  atrophy ;  again, 
in  the  former  the  atrophy  is  partial,  and  in  the  latter  the 
muscle  wastes  as  a  whole.  In  progressive  muscular  atrophy 
the  middle  form  of  the  reaction  of  degeneration  is  met  with, 
and  reflex  action  is  retained ;  while  in  chronic  atrophic  spinal 
paralysis  the  reaction  of  degeneration  is  well  marked  and  reflex 
action  is  abolished;  and,  lastly,  progressive  muscular  atrophy 
runs  a  slow  and  always  unfavourable  course,  while  chronic 
poliomyelitis  runs  a  comparatively  rapid  course  and  frequently 
ends  favourably.  It  is  not  improbable  that  some  cases  which 
are  usually  classed  as  partial  progressive  muscular  atrophy,  but 
which  are  not  progressive,  really  belong  to  the  category  of 
chronic  anterior  poliomyelitis. 

Amyotrophic  lateral  sclerosis  resembles  chronic  poliomyelitis 
in  the  paralysis  and  atrophy  of  the  muscles  of  the  upper  ex- 
tremities, but  in  the  lower  extremities  there  is  paralysis  without 
atrophy  along  with  tension  of  the  muscles,  contractures,  and 
increase  of  the  tendon  reflexes,  and  only  the  middle  form  of  the 
reaction  of  degeneration  is  met  with.  The  diagnosis  between 
paralysis  ascendens  acuta  and  chronic  poliomyelitis  will  be 
subsequently  described. 

Chronic  atrophic  spinal  paralysis  may  be  distinguished  from 
transverse  myelitis,  multiple  sclerosis,  tabes  dorsalis,  spastic 
spinal  paralysis,  and  all  other  forms  of  chronic  spinal  disease, 
if  due  attention  be  paid  to  the  state  of  the  sensibility,  the 


SPINAL   COED  AND   MEDULLA   OBLONGATA.  145 

functions  of  the  bladder,  the  nutrition  of  the  skin,  reflex  action, 
and  the  electrical  excitability  of  the  muscles. 

§  408.  Prognosis. — The  prognosis  is  comparatively  favourable. 
Recovery  takes  place  in  the  majority  of  cases,  and  improvement, 
as  a  rule,  goes  much  further  than  in  the  acute  form.  At  th-e 
same  time  it  must  be  remembered  that  chronic  atrophic  spinal 
paralysis  is  not  like  infantile  paralysis  in  being  free  from  all 
danger  to  life.  The  more  partial  forms  of  the  disease  are  never 
dangerous  to  life,  although  they  may  lead  to  permanent  atrophy 
of  the  muscles  affected. 

§  409.  Treatment.- — The  same  principles  are  applicable  in  the 
treatment  of  this  disease  as  for  subacute  and  chronic  myelitis 
generally.  Antiphlogistic  treatment  should  first  be  employed, 
and  afterwards  the  use  of  the  galvanic  current  and  a  stimulating 
and  supporting  treatment. 

3.  Progressive  Muscular  Atrophy. 
Progressive  muscular  atrophy  is,  as  its  name  implies,  a  pro- 
gressive wasting  of  the  voluntary  muscles,  which  pursues  a 
chronic  course,  and  attacks  successively  individual  muscles  and 
groups  of  muscles. 

§  410.  ^is;or_?/.— Hippocrates  made  a  distinction  between  paralysis 
with  and  without  wasting  of  the  limbs,  and  observed  that  the  former  was 
incurable.  Cases  of  muscular  wasting,  but  without  paralysis,  were  pub- 
lished in  the  first  half  of  this  century  by  Abercrombie,  Darwal,  Cooke, 
Bell,  Romberg,  Graves,  Dubois,  and  Duchenne,  but  the  affection  was  not 
recognised  as  a  distinct  disease.  Duchenne,  Aran,  and  Cruveilhier,  in  1850, 
independently  of  each  other,  gave  more  accurate  descriptions  of  the 
affection,  and  recognised  its  claims  to  be  regarded  as  a  distinct  type  of 
disease.  Dr.  William  Eoberts  in  1858  collected  all  the  information 
existing  on  the  subject  up  to  that  time  in  an  essay  entitled  "  On  Wasting 
Palsy  ;"  and  since  that  time  the  pathology  of  the  disease  has  been  in- 
vestigated by  Gull,  Lockhart  Clarke,  Luys,  Charcot,  Hayem,  Leyden, 
Friedreich,  Erb,  and  many  others. 

§  411,  Etiology. — Hereditary  predisposition  is  a  powerful 
factor  in  the  production  of  progressive  muscular  atrophy.  Dr. 
Roberts   collected    the   histories   of  ten  families  in  which   a 


146  SYSTEM  DISEASES  OF  THE 

tendency  to  the  disease  prevailed;  but  the  cases  described  by  Dr. 
Meryon,  which  are  included  in  this  list,  were  probably  instances 
of  the  advanced  stage  of  pseudo-hypertrophic  paralysis.  After 
Dr.  Meryon's  cases  are  eliminated,  it  may  be  stated  that  out  of 
the  eight  families  referred  to  by  Dr.  Roberts  twenty-three  indivi- 
duals were  affected,  and  of  these  four  only  were  females. 

In  a  case  described  by  Hemptenmacher,  the  disease  could  be 
traced  amongst  the  branches  of  three  families,  who  had  re- 
peatedly intermarried,  and  who  had  sprung  from  one  parentage 
a  hundred  and  fifty  years  ago.  In  this  instance  males  only  were 
attacked,  but  the  disease  was  frequently  transmitted  through 
the  female.  Friedreich  found  that  the  disease  was  transmitted 
by  a  woman  to  her  children,  though  they  were  the  products  of 
three  separate  marriages.  Trousseau  mentions  a  family  in  which 
the  great-grandfather,  grandfather,  father,  and  son  suffered  from 
the  disease,  the  course  of  which  closely  coincided  in  all  the 
generations.  Eulenburg  mentions  the  case  of  a  family  where, 
out  of  seven  children,  two  brothers  and  two  sisters  were 
attacked,  while  the  remaining  three  brothers  escaped. 

The  male  sex  shows  a  much  greater  tendency  to  the  disease 
than  the  female  sex.  Out  of  176  cases  collected  by  Friedreich 
only  33  were  females.  The  disproportion  between  the  sexes 
probably  depends  on  men  being  much  more  exposed  to  the 
exciting  causes  of  the  disease.  Dr.  Roberts  asserts  that  women 
of  the  working  classes,  such  as  washerwomen,  domestic  servants, 
and  sempstresses,  are  not  much  less  liable  to  the  disease  than 
men  employed  in  kindred  occupations,  while  on  the  other  hand 
females  belonging  to  the  middle  and  upper  classes  enjoy  a 
remarkable  immunity  from  the  disease.  It  is  difficult  to 
explain  the  cases  which  arise  in  childhood  and  in  which  the 
male  members  of  the  family  alone  are  attacked.  Mr.  Darwin, 
however,  has  shown  that  many  variations  which  first  appear  in 
one  sex  are  transmitted  to  that  sex  only.  If  this  fact  does  not 
afford  an  explanation,  it  at  least  merges  the  special  into  a 
general  difficulty.  With  regard  to  the  influence  of  age,  the 
disease  is  found  amongst  young  adults  and  middle-aged  in- 
dividuals ;  and  where  there  is  a  marked  hereditary  tendency 
to  the  affection,  children  are  not  unfrequently  attacked.  The 
development  of  the  disease  in  advanced  life  is  exceptional. 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  147 

Progressive  muscular  atrophy  is  often  developed  during  con- 
valescence from  acute  diseases,  such  as  typhoid  fever,  measles, 
acute  rheumatism,  and  cholera  with  protracted  typhoid  stage; 
and  Charcot  and  Joffroy  have  observed  it  to  occur  immediately 
after  childbed.  Venereal  excess,  especially  onanism,  has  been 
supposed  by  many  authors  to  be  a  fruitful  source  of  the  affec- 
tion, although  the  evidence  upon  which  the  opinion  is  founded 
is  doubtful.  Chronic  lead  poisoning  is  not  unfrequently 
attended  by  a  diffused  wasting  of  the  muscles,  closely  resem- 
bling progressive  muscular  atrophy ;  and  a  similar  wasting  also 
occurs  in  constitutional  syphilis. 

Of  the  exciting  causes  of  the  disease  unusual  muscular 
exertion  deserves  the  chief  place.  That  excessive  muscular 
efforts  tend  to  develop  the  disease  is  shown  by  the  fact  that  the 
atrophy  attacks  by  preference  the  groups  of  muscles  which 
must  be  maintained  in  long-continued  contraction  with  persons 
following  certain  avocations,  such  as  blacksmiths,  tailors, 
masons,  and  shoemakers.  Betz  observed  atrophy  of  the 
muscles  of  the  right  side  in  smiths  and  saddlers,  who  had  to 
do  heavy  work  with  their  right  hands,  and  Gull  observed  the 
same  in  a  tailor  after  excessive  exertion.  In  the  case  of  a 
stonemason  which  came  under  my  notice  the  atrophy  began  in 
the  muscles  of  the  right  hand.  In  persons  who  have  to  per- 
form manual  labour  the  disease  generally  begins  in  the  muscles 
of  the  shoulders,  arms,  and  hands ;  and  the  right  side  is 
generally  the  first  to  be  affected.  In  children  the  atrophy  not 
unfrequently  begins  in  the  lumbar  muscles,  and  extends  to 
those  of  the  lower  extremities,  a  mode  of  invasion  which  is 
probably  due  to  the  preponderant  use  of  these  muscles  in 
standing  and  walking.  I  have  observed  a  similar  mode  of 
invasion  in  a  collier,  who  was  compelled  to  work  in  a  bent 
posture. 

Exposure  to  cold  and  wet  appears  to  be  of  itself  sufficient  to 
produce  the  disease.  C.  H.  Richter  saw  a  total  atrophy  of  the 
hands  in  a  man  who  suffered  from  severe  sweating  of  the  hands 
and  who  was  accustomed  to  bathe  them  in  ice-cold  water  and 
snow.  Dumdoil  observed  atrophy  of  the  lower  extremities 
after  long-continued  standing  in  water  while  fishing  ;  but  in 
this   case   it   is   doubtful  how   much  of  the  effect   is   to   be 


148  SYSTEM  DISEASES   OF  THE 

attributed  to  exposure  to  cold  and  how  much  to  excess  of 
muscular  exertion.  The  disease  is  doubtless  more  likely  to 
be  developed  when  these  causes  are  combined.  Cases  arising 
from  exposure  to  cold  are  subject  to  neuralgic  or  rheumatic 
pains  in  the  affected  parts,  hence  these  cases  are  frequently- 
assumed  to  be  due  to  rheumatism.  In  this  class  of  cases  the 
invasion  is  often  sudden  and  accompanied  by  cramps  and  mus- 
cular twitching  (Roberts),  and  the  atrophy  is  more  apt  to 
extend  to  the  muscles  of  the  trunk  than  in  cases  due  to 
overwork.  According  to  Dr.  Roberts,  of  twenty-five  cases 
attributed  to  overwork  eighteen  were  partial  and  only  seven 
general ;  whereas  of  the  sixteen  cases  charged  to  the  agency  of 
cold  six  were  local  and  ten  general. 

Injuries  of  various  kinds  may  be  the  exciting  causes  of  this 
affection.  In  a  youth,  under  the  care  of  Dr.  Roberts,  who 
ultimately  died  from  implication  of  the  respiratory  muscles,  the 
first  symptom  of  atrophy  occurred  in  the  ball  of  the  right 
thumb  six  months  after  the  fall  of  a  bale  of  cotton  on  his  neck. 
Cases  similar  in  essential  particulars  are  recorded  by  Clarke 
and  other  authors.  Local  injury  to  some  of  the  muscles  of  the 
body  is  sometimes  followed  by  progressive  muscular  atrophy. 
Friedreich  relates  a  case  in  which  the  hand  had  been  crushed, 
and  subsequently  the  atrophy  extended  progressively  upwards 
over  the  entire  upper  extremity,  and  finally  led  to  the  com- 
plication of  bulbar  paralysis.  At  other  times  the  inflammatory 
irritation  appears  to  be  propagated  from  neighbouring  parts, 
such  as  the  shoulder  and  hip  joints,  and  the  disease  appears  at 
times  to  have  been  caused  by  cicatrices  or  suppurating  wounds. 
These  cases  are  grouped  by  Friedreich  under  the  name  of 
myopathica  propagata. 

§  412.  Symptoms. — The  invasion  of  the  disease  is  slow  and 
insidious,  and  it  is  usually  in  existence  some  weeks  or  months 
before  its  presence  is  discovered.  The  patient  first  experiences 
some  difficulty  in  performing  certain  movements;  and  on  atten- 
tion being  directed  to  the  affected  limbs,  some  of  the  muscles 
are  discovered  to  be  more  or  less  wasted.  At  other  times, 
especially  when  the  disease  has  been  caused  by  exposure  to 
cold,  the   mode  of  invasion  is  attended  by  more  prominent 


SPINAL   CORD   AND  MEDULLA  OBLONGATA.  149 

symptoms.  Paroxysmal  pains,  like  those  of  rheumatism  or  of 
neuralgia,  are  felt  in  the  affected  limb  several  weeks  or  months 
before  the  atrophy  of  the  muscles  is  noticed,  and  when  once 
the  atrophy  begins  in  these  cases  it  proceeds  more  rapidly  and 
becomes  more  generalised  than  in  the  painless  variety. 

The  disease  usually  begins  in  one  of  the  upper  extremities, 
more  commonly  in  the  right,  either  in  the  interossei,  the 
muscles  of  the  thenar  and  hypothenar  eminences,  or  in  those 
of  the  shoulder,  Eulenburg  says  that  when  the  disease  begins 
in  the  hand  the  interossei  (and  especially  the  first  interosseus) 
are  generally  attacked  before  the  muscles  of  the  ball  of  the 
thumb;  while  the  contrary  opinion  is  held  by  Roberts  and 
Friedreich,  The  opponens  pollicis  and  the  adductor  pollicis 
are  the  first  muscles  to  be  affected  in  the  ball  of  the  thumb, 
while  the  extensors,  abductor,  and  flexor  of  the  thumb  are 
spared  for  a  long  time,  or  may  escape. 

In  some  few  cases  the  disease  begins  in  the  muscles  of  the 
shoulder,  and  in  these  the  deltoid  is  almost  always  exclusively 
affected  at  first.  When  the  atrophy  begins  in  the  lumbar 
muscles  and  lower  extremities  children  are  almost  always  the 
subjects  of  the  disease,  and  it  then  frequently  simulates 
pseudo-hypertrophic  paralysis,  which  will  be  subsequently 
described.  During  the  progress  of  the  disease  certain  muscles 
or  groups  of  muscles  are  attacked  while  their  neighbours  are 
spared,  and  the  healthy  or  less  atrophied  muscles  overcome 
the  resistance  of  those  more  diseased,  so  that  characteristic 
contractions  and  deformities  are  produced. 

The  disappearance  of  the  interossei  is  shown  by  the  deep 
furrows  which  appear  between  the  metacarpal  bones,  the 
thenar  and  hypothenar  eminences  are  flattened,  and  the  dis- 
appearance of  the  muscles  of  the  palm  brings  into  view  the 
diverging  flexor  tendons  which  are  stretched  between  the  wrists 
and  the  bulging  bases  of  the  fingers  (Roberts).  The  deformity 
produced  by  paralysis  of  the  interossei  gives  to  the  hand  the 
appearance  of  the  talons  of  a  bird  of  prey  ;  hence  it  has  been 
called  the  claw-shaped  hand  or  main  en  griff e  {Fig.  77),  This 
deformity,  however,  is  not  peculiar  to  progressive  muscular 
atrophy,  inasmuch  as  it  may  be  caused  by  injury  to  the  ulnar 
nerve.     In  consequence  of  the  atrophy  of  the  opponens  and 


150  SYSTEM  DISEASES  OF  THE 

adductor  pollicis,  the  thumb  is  extended  and  abducted  (Plate 
II,  1,  2,  S). 

When  the  forearm  is  affected,  the  anterior,  posterior,  or 
exterior  aspect  of  the  limb  is  flattened  according  as  the  flexors, 
extensors,  or  supinators  are  affected. 

When  the  muscles  of  the  shoulders  are  affected,  the  arms  may- 
hang  by  the  side  or  rather  in  front  of  the  patient,  as  if  they  were 
merely  attached  to  him  by  strings  and  did  not  belong  to  him ; 
the  natural  rounded  configuration  of  the  shoulders  is  replaced 
by  a  hollow  in  which  the  palm  of  the  hand  may  be  lodged 
under  the  projecting  acromial  and  coracoid  processes  of  the 
scapula,  which  stand  out  in  relief  The  biceps  and  the  other 
muscles  of  the  arm  may  also  waste,  so  that  the  limb  loses  its 
roundness  and  becomes  flattened,  and  the  humerus  appears 
to  be  surrounded  merely  by  the  skin. 

When  the  abdominal  muscles  are  affected,  the  lumbar  curve 
is  greatly  exaggerated  by  the  unopposed  action  of  the  erector 
spinse,  the  abdomen  is  loose  and  protruding,  but  the  thorax  is 
held  well  forwards,  so  that  a  plumb-line  let  drop  from  the  most 
prominent  of  the  spinous  processes  of  the  vertebrae  will  pass 
well  within  the  sacrum,  contrary  to  what  occurs  when  the 
lumbar  muscles  are  affected.  When  the  atrophy  is  unequally 
distributed  on  both  sides  of  the  body,  scoliotic  or  kyphotic 
bending  of  the  vertebral  column  may  be  produced.  When 
the  erector  spinse  and  extensors  of  the  thigh  are  implicated, 
the  deformities  produced,  as  well  as  the  gait,  are  very  similar 
to  those  seen  in  pseudo-hypertrophic  paralysis,  and  it  is  un- 
necessary to  describe  them  here. 

When  the  lower  extremities  are  invaded,  deformities  occur 
corresponding  to  those  observed  in  the  upper  extremities; 
but  the  former  are  of  much  rarer  occurrence  than  the  latter. 
The  various  forms  of  club-foot  may  appear,  especially  the  para- 
lytic pes  equino-varus. 

The  accessory  respiratory  muscles,  as  the  pectoralis  major, 
serratus  magnus,  trapezius,  &c.,  are  frequently  implicated ;  and 
although  the  wasting  and  loss  of  power  of  these  muscles  do  not 
directly  endanger  life,  yet  they  may  do  so  indirectly,  inasmuch 
as  a  slight  intercurrent  attack  of  bronchitis  may  lead  to 
asphyxia  since  the  inability  to  make  a  strong  expiratory  effort 


i'l:vtk  II 


iMiH^fV:^^  '*■' 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  151 

prevents  the  tubes  from  being  effectually  cleared  of  mucus.  In 
the  later  stages  of  the  affection,  the  diaphragm  and  the  inter- 
costal muscles  become  affected,  expectoration  fails,  mucus  collects 
in  the  tubes,  and  the  patient  dies  asphyxiated. 

The  facial,  lingual,  and  laryngeal  muscles,  as  well  as  the 
muscles  of  deglutition,  are  frequently  affected  towards  the  ter- 
minal period  of  the  disease ;  but  the  symptoms  caused  by 
implication  of  these  muscles  will  be  described  as  labio-glosso- 
laryngeal  paralysis. 

As  the  following  case,  which  is  carefully  reported  by  Mr. 
CuUingworth,*  affords  a  good  example  of  progressive  muscular 
atrophy,  where  the  muscles  of  the  back  and  some  of  the 
muscular  groups  of  the  lower  extremities  are  affected,  I  shall 
quote  it  at  length  : — 

Charlotte  A ,  aged  forty-one,  admitted  into  St.  Mary's  Hospital, 

Manchester,  February  3,  1878.  She  is  married,  and  has  had  three  living 
children,  all  of  whom  died  in  infancy.  There  is  no  family  history  of 
nervous  disorder  or  of  impairment  of  power  of  locomotion.  Her  father, 
an  intemperate  man,  died  of  chest  disease  at  the  age  of  thirty-six ;  her 
mother  died  in  her  fiftieth  year  of  heart  disease.  Of  six  brothers  and 
sisters,  two  died  in  infancy,  one  from  the  consequences  of  her  husband's 
ill-treatment,  and  three  are  living  in  good  health. 

She  worked  in  a  factory  from  the  age  of  nineteen  until  five  years  ago, 
having  had  constantly  two,  and  sometimes  more,  looms  under  her  charge. 
The  nature  of  her  work  necessitated  the  stooping  posture,  and  for  some 
years  this  had  been  a  painful  strain  to  her.  She  was  a  long  time  in 
straightening  herself  when  the  day's  labour  was  over,  and  the  process  was 
not  only  difficult  but  painful.  About  six  years  ago,  when  she  was  preg- 
nant of  her  last  child,  she  was  suddenly  seized  with  an  attack  of  uncon- 
sciousness while  at  her  work ;  she  fell  down,  and  was  carried  unconscious 
home.  She  had  other  attacks  of  the  same  kind  both  before  and  after  her 
confinement,  and,  indeed,  had  one  shortly  before  her  admission.  Her 
husband  says  that  there  is  absolutely  no  warning,  that  she  frequently 
hurts  herself  in  falling,  that  she  foams  at  the  mouth  and  rolls  her  eyes, 
but  that  there  is  no  violent  struggling.  It  was  on  account  of  these  fits 
that  her  overlooker  advised  her,  for  her  own  safety,  to  cease  work  several 
years  ago.  She  cannot  tell  exactly  when  the  peculiarity  in  walking  was 
first  noticed,  but  is  certain  that  she  has  had  difficulty  in  rising  from  a 
chair  ever  since  her  last  confinement.  This  difficulty  has  gradually 
increased. 

She  is  a  thin,  sallow-complexioned  woman,  of  average  height,  and  of 

*  The  Medical  Times  and  Gazette,  vol.  ii.,  1878,  p.  121. 


152 


SYSTEM  DISEASES   OF  THE 


feeble  intellectual  power.  Her  lips  become  markedly  livid  on  the  least 
exertion  or  exposure;  the  whole  body  is  sensitive  to  cold.  There  is 
nothing  abnormal  in  the  condition  of  the  thoracic  or  abdominal  viscera. 

Examination  while  Standing. — The  head  is  erect,  and  movable  by  the 
patient  in  all  directions ;  the  shoulders  are  somewhat  higher  than  usual  in 
a  woman ;  the  upper  part  of  the  spine  is  carried  backwards  more  than 
usual.  A  plumb-line  from  the  most  prominent  of  the  spines  of  the  upper 
dorsal  vertebrae  falls  an  inch  behind  and  away  from  the  sacrum.  The 
knees  are  very  slightly  bent ;  the  feet  are  placed  firmly  on  the  ground, 
with  the  heels  touching,  the  toes  turned  outwards  and  extended  naturally. 
The  upper  extremities  present  no  appearance  of  muscular  deficiency,  and 
the  deltoids  are  prominent  and  well  developed.  The  lower  extremities 
present  this  anomaly :  that  while  the  thighs  are  thinner,  softer,  and  more 
flaccid  than  natural,  the  calves,  on  the  contrary,  are  of  a  size  quite  out  of 
proportion  with  the  muscular  development  of  the  rest  of  the  body.  The 
following  measurements  were  taken  : — Circumference  of  upper  arm  below 
pectorals,  9|in. ;  forearm  at  thickest  part,  9^in. ;  middle  of  thigh,  16in. ; 
thickest  part  of  calf,  14jin.  It  will  thus  be  seen  that  the  circumference 
of  the  calf  is  nearly  equal  to  that  of  the  middle   of  the  thigh.     This 


Fig.  164. 


Fig.  165. 


Fig.  164  shows  the  position  assumed  by  the  scapulae  when  the  arms  are  extended 
forwards.  There  is  a  deep  sulcus  between  the  two  bones,  the  posterior  borders 
of  which  project  two  inches  from  the  costal  wall.  The  posterior  border  of  the 
left  scapula  is  parallel  with  the  median  line,  having  been  adjusted  by  the  action 
of  the  serratus  magnus,  whose  fibres  (passing  downwards,  outwards,  and  for- 
wards from  the  lower  angle)  are  seen  contracting  beneath  a  fold  of  skin.  This 
movement  of  adjustment  has  not  yet  taken  place  on  the  right  side,  where  the 
lower  angle  of  the  scapula  is  nearer  the  vertebral  column,  a  little  higher,  and 
altogether  more  prominent  than  on  the  opposite  side,  owing  to  the  unopposed 
action  of  the  deltoid ;  the  serratus  magnus,  being  in  a  condition  of  relaxation,  is 
much  less  noticeable  on  this  (right)  side.  The  transverse  fibres  of  the  trapezius, 
passing  from  the  outer  half  of  the  spine  of  the  scapula  to  the  last  cervical  and 
first  dorsal  vertebrae,  are  well  seen  ;  with  these  fibres  the  upper  and  unaflfected 
half  of  the  muscle  abruptly  terminates. 

Fig.  165  shows  the  appearance  of  the  back  when  a  healthy  subject  is  placed  in  the 
same  attitude.  The  scapulae  are  applied  so  closely  against  the  costal  wall  that, 
although  the  person  is  by  no  means  stout,  the  outline  of  the  bone  is  scarcely 
traceable.    The  lower  angle  is  in  the  axillary  line. 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  153 

circumstance  gave  rise  to  a  suspicion  of  pseudo-hypertrophy,  and  a  minute 
portion  of  muscle  was  withdrawn  from  the  calf  by  the  muscle-trocar,  and 
kindly  examined  for  me  under  the  microscope  by  my  friend  Dr.  Dreschfeld. 
The  muscular  tissue  was  not  found  to  have  undergone  any  change. 

As  the  patient  stands  at  ease,  with  her  back  to  the  observer,  attention  is 
at  once  attracted  to  the  unusual  projection  of  the  posterior  borders  of  the 
scapulse.  They  stand  back  an  inch  from  the  posterior  chest-wall,  retaining 
their  parallelism  with  the  median  line,  and  leaving  a  fossa  between  them  four 
inches  in  breadth  and  an  inch  in  depth,  bounded  on  each  side  by  a  wall  of 
skin,  which  passes  perpendicularly  from  the  scapular  borders  to  the  back  of 
the  thorax.  The  condition  of  the  inter-scapular  muscles  can  be  best  studied 
when  the  arms  are  held  horizontally  forwards  {Fig.  164,  and  Plate  II., 
4  and  6).  The  spinal  borders  of  the  scapulse  then  project  backwards 
to  a  distance  of  two  inches  from  the  chest-wall,  and  approach  within  an 
inch  and  a  half  of  each  other,  still  preserving  their  parallelism.  Between 
the  anterior  surface  of  the  scapulse  and  the  chest- wall  there  is  a  deep  groove 
posteriorly,  easily  admitting  the  tips  of  the  fingers  when  they  are  bent 
over  the  posterior  edge  of  the  scapula.  The  trapezius,  perfectly  developed 
in  its  clavicular  portion  and  in  the  upper  half  of  its  middle  third,  ter- 
minates abruptly  by  a  strong  bundle  of  fibres  stretching  across  from  the 
spinous  processes  of  the  last  cervical  and  first  dorsal  vertebrse  to  the  outer 
half  of  the  spine  of  the  scapula.  There  is  not  a  trace  of  the  muscle  to  be 
felt  below  this  point.  Between  the  posterior  border  of  the  scapulae  and 
the  spinal  column  there  are  no  muscular  fibres  to  be  felt,  except  one  little 
thin  band  passing  to  the  middle  of  the  edge  of  the  scapula.  This  is  all 
that  remains  of  the  rhomboids.  The  latissimus  dorsi  has  also  disappeared, 
and  there  is  no  response  to  the  strongest  faradic  current  in  the  course 
either  of  this  muscle  or  of  the  lower  half  of  the  trapezius,  or  of  the  rhom- 
boids, except  in  the  slender  fasciculus  of  fibres  just  named.  On  the  other 
hand,  the  levator  anguli  scapulse  and  serratus  magnus  can  be  felt  to  con- 
tract forcibly,  and  they  respond  readily  to  a  moderate  current.  The  lower 
segment  of  the  latter  muscle,  passing  downwards  and  forwards  from  the 
lower  angle  of  the  scapula  to  the  lower  ribs,  stands  out  prominently  when 
the  arms  are  raised ;  and,  being  uncovered  by  the  latissimus  dorsi,  can  be 
grasped  underneath  the  skin,  which  is  raised  into  a  fold  by  the  contraction 
of  the  muscle.  The  deep  scapular  muscles  (supra-spinatus,  infra-spinatus, 
sub-scapularis,  teres  minor,  and  teres  major)  are  well  developed  and  easily 
defined.     The  pectoral  muscles  are  also  unafiected. 

The  patient  cannot  elevate  her  arms  vertically  ;  the  nearest  approach 
to  this  which  she  can  make  is  to  raise  her  elbows  until  they  are  on  a  level 
with  the  ears,  at  a  distance  of  about  nine  inches  from  the  head.  When 
this  position  is  assumed,  instead  of  the  scapulse  being  closely  applied  to 
the  chest-wall,  and  rotated  so  as  to  bring  the  lower  angle  outwards  and 
forwards  as  far  as  the  axillary  line,  the  posterior  borders  of  the  scapulse 
are  brought  into  actual  contact  with  each  other  at  their  upper  extremity, 
slightly  diverging  from  above  downwards,  so  that  the  lower  angles  are  two 


154! 


SYSTEM  DISEASES  OF   THE 


Fig,  166. 


inches  apart.  The  anterior  face  of  the  scapula  is  in  the  meantime  one 
inch  and  three-quarters  behind  and  away  from  the  thorax.  When  the 
arms  are  stretched  out  horizontally  right  and  left,  the  posterior  borders  of 
the  scapulae  touch  each  other  both  at  their  upper  and  lower  angles,  on  a 
plane  one  inch  and  three-quarters  behind  the  chest-wall.  If  the  patient 
places  one  hand  upon  the  opposite  shoulder,  the  scapula  assumes  the 
following  position  : — The  external  angle  is  raised  along  with  the  whole 
shoulder,  the  internal  angle  is  depressed,  the  inferior  angle  is  drawn  out- 
wards, the  posterior  border  projects  an  inch  from  the  chest-wall  and  is 
distant  from  the  vertebral  column  three  inches  at  its  upper  end  and  four 

inches  at  its  lower.  When,  again,  the 
shoulders  are  drawn  back,  the  elbows 
placed  by  the  side  and  flexed,  so  that 
the  fingers  point  Upwards,  with  their 
palmar  aspect  directed  forwards,  the 
posterior  borders  of  the  scapulse  are 
pressed  forcibly  together,  closing  over 
the  vertebral  column  on  a  plane  two 
inches  behind  it  (see  Fig.  166). 

The  patient,  in  attempting  to  carry 
the  arm  behind  the  trunk,  cannot 
rotate  it  so  as  to  direct  the  posterior 
aspect  of  the  upper  arm  outwards,  or 
carry  the  upper  arm  from  the  plane  of 
the  axilla  towards  the  middle  line  of 
the  back. 

Walking. — In  walking  there  is  a 
general  unsteadiness  of  gait,  but  no 
waddling.  The  knees  are  slightly 
flexed,  and  the  head  and  shoulders  are 
held  well  back,  so  that  the  feet  are 
always  kept  in  front  of  the  patient. 
The  mode  of  progression  remains  un- 
altered when  the  patient  closes  her 
eyes.  Ascending  stairs  is  a  matter  of 
extreme  difl&culty,  and  it  is  exceed- 
ingly painful  to  witness  her  condition 
of  exhaustion  and  lividity  after  making 
the  efibrt. 

Sitting. — When  about  to  sit  dowa 
she  steadies  herself  for  a  moment, 
grasps  her  thighs  firmly  with  her 
hands,  and  falls  suddenly  on  to  the 
chair  as  though  the  trunk  were  a  dead 
weight.  At  the  moment,  and  in  the 
act  of  sitting  down,  the  trunk  is  in- 


FlG.  166  shows  the  patient,  Char- 
lotte A ,  when  the  shoulders 

are  thrown  back  and  the  scapulas 
brought  together.  The  posterior 
borders  are  partially  in  contact 
on  a  plane  two  inches  behind  the 
costal  wall.  The  sharp  edge  of 
the  unaffected  half  of  the  trape- 
zius is  again  clearly  seen,  as  well 
as  the  inferior  segment  of  the 
serratus  magnus  on  each  side. 
The  levator  anguli  scapulse  is 
acting  more  powerfully  on  the 
left  than  the  right.  This  draw- 
ing also  shows  the  loss  of  rotun- 
dity in  the  gluteal  region,  and 
the  remarkable  contrast  between 
the  hypertrophied  calf  and  the 
attenuated  muscles  of  the  thigh. 


SPINAL  CORD  AND  MEDULLA   OBLONGATA.  155 

voluntarily  thrown  forwards  upon  the  thighs,  and  it  remains  in  that 
position  until  by  moving  the  feet  forward  and  planting  them  firmly,  and 
by  then  grasping  the  knees,  she  pushes  up  the  trunk  into  the  erect 
posture  "  by  force  of  arms." 

Rising  from  the  Sitting  Posture, — She  rises  from  the  sitting  posture 
with  great  difficulty,  and  in  the  following  manner  : — Compressing  her 
lips,  she  separates  the  feet  widely,  and  grasps  both  her  knees  ;  she  then 
flexes  the  trunk  upon  the  thighs  until  the  trunk  is  horizontal,  and  raises 
the  buttocks  from  the  chair  by  a  movement  of  extension  at  the  knee.  In 
this  stooping  attitude  she  shufl9.es  away  from  the  chair  until  she  reaches 
something  to  lay  hold  of — mantelpiece,  table,  or  bystander — when,  having 
rested  for  a  moment,  she  raises  the  hands,  one  by  one,  from  the  knees, 
and  clutches  firmly  the  object  near  which  she  has  halted.  Then  very 
slowly  and  with  great  effort,  keeping  the  back  stiflf  and  straight,  she  raises 
herself  by  means  of  the  arms  into  the  upright  position.  The  mode  in 
which  she  rises  from  the  floor  is  even  more  painful  to  witness.  Placing 
her  hands  on  the  ground  in  front  of  her,  she  first  of  all  scrambles  on  to 
her  hands  and  knees.  In  this  posture  she  makes  her  way  to  the  nearest 
available  article  of  furniture,  seizing  which,  she  regains  her  feet.  The 
trunk,  however,  is  still  horizontal,  and  it  is  the  tremendous,  and  for  a  long 
time  futile,  efforts  that  she  now  makes  to  straighten  herself  that  consti- 
tute the  most  distressing  part  of  the  performance.  Striving  to  obtain  a 
firm  purchase  with  her  feet,  the  knees  being  fully  extended,  the  feet  slip 
backwards  time  after  time.  Eventually,  after  violent  exertions,  which 
leave  her  exhausted  and  breathless,  she  accomplishes  her  task. 

Flexion  of  Thigh  upon  Pelvis,  Sc. — When  lying  in  bed  horizontally 
upon  the  back,  she  is  able  to  flex  the  leg  upon  the  thigh,  and  the  thigh 
upon  the  trunk,  so  long  as  the  heel  remains  upon  the  bed ;  but  when  the 
leg  is  fully  extended  she  is  unable  to  lift  the  heel  a  single  inch  from  the 
plane  of  the  bed.  As  she  sits,  with  the  knees  flexed,  she  cannot  raise  the 
foot  from  the  ground ;  but  the  movements  of  adduction  and  abduction 
are  accomplished  fairly  well.  She  crosses  one  thigh  over  the  other  by  the 
following  manoeuvre  : — Supposing  the  right  thigh  is  to  be  crossed  over  the 
left,  the  left  knee,  bent  to  an  acute  angle,  is  adducted  and  pushed  under 
the  right  knee,  which  latter  is  thus  lifted  up  and  carried  over  to  the  left 
side,  resting  upon  its  fellow. 

Ankle. — The  movements  at  the  ankle-joint  are  performed  without 
difl&culty. 

Owing  to  the  kindness  of  Mr.  Cullingworth  I  have  had 
repeated  opportunities  of  examining  this  woman,  and  the  only 
addition  I  should  like  to  make  to  his  valuable  report  of  the 
case  is  to  draw  attention  to  the  gait  of  the  patient,  especially 
noting  the  points  in  which  it  differs  from  the  gait  characteristic 
of  pseudo-hypertrophic  paralysis. 


156  SYSTEM   DISEASES  OF  THE 

In  the  case  of  this  woman  the  feet  are  held  close  to  each  other,  and,  as 
Mr.  CuUingworth  observes,  the  gait  is  not  waddling.  In  walking  the  head 
does  not  deviate  laterally  from  the  middle  line  during  the  transference  of 
the  centre  of  gravity  from  the  active  to  the  passive  leg,  but  it  may  be 
observed  to  advance  by  a  series  of  vertical  curves.  In  his  remarks  on  the 
case  Mr.  CuUingworth  observes  that  the  patient  is  unable,  when  lying 
horizontally  on  her  side  with  the  legs  extended,  to  separate  her  thighs, 
thus  showing  that  the  gluteus  medius  and  minimus  are,  at  least  to  some 
extent,  affected  by  paralysis.  On  placing  one's  own  hands  over  the  pelvis 
of  the  patient,  one  being  held  on  each  side  immediately  above  the  tro- 
chanter of  the  femur,  it  is  felt  that  the  gluteus  medius  on  the  side  of  the 
active  leg  does  not  contract  during  locomotion.  The  consequence  is  that, 
instead  of  the  pelvis  on  the  side  of  the  passive  leg  being  slightly  elevated 
as  in  health,  by  the  contraction  of  the  gluteus  medius  of  the  opposite 
side,  so  as  to  allow  the  leg  to  swing  forwards,  it  is  distinctly  felt  to  drop 
on  that  side  to  a  lower  level.  The  pelvis,  therefore,  forms  a  more  or  less 
acute  angle  with  the  active  leg  instead  of,  as  in  health,  forming  an  obtuse 
angle  with  it.  It  is,  however,  maintained  in  a  nearly  horizontal  position 
by  the  fact  that  the  active  leg  itself  slants  downwards  and  inwards  from 
the  hip-joint.  The  line  of  gravity  passes  through  the  pelvis  about  its 
middle  ;  and  in  order  that  it  may  pass  through  the  arch  of  the  foot  of 
the  active  leg,  the  latter  must  occupy  a  position  directly  below  the  middle 
of  the  pelvis,  and  consequently  the  hip  of  that  side  projects  outwards. 
The  passive  leg  is  prevented  from  swinging  forwards  with  the  normal 
pendulum  motion,  inasmuch  as  the  hip-joint  on  that  side  becomes  lower 
when  the  leg  is  raised  off  the  ground,  instead  of  being  elevated  by  con- 
traction of  the  gluteus  medius  of  the  opposite  side  as  in  health.  The 
necessary  elevation  of  the  passive  foot  is  obtained  by  strong  flexion  of 
the  thigh  upon  the  body,  so  that  the  legs,  as  described  by  Mr.  CuUing- 
worth, appear  to  be  in  advance  of  the  body.  The  alternate  projection  of 
the  hip  on  the  side  of  the  active  leg,  and  the  alternate  falling  down  of 
the  hip  on  the  side  of  the  passive  leg  during  successive  steps,  render  the 
gait  of  this  patient  totally  unlike  that  which  is  so  characteristic  of  pseudo- 
hypertrophic paralysis. 

The  loss  of  muscular  power  keeps  pace  with  the  atrophy,  and 
is,  as  a  rule,  directly  in  proportion  to  the  degree  of  the  latter, 
and  so  long  as  any  muscular  fibres  are  left,  they  can  be  made 
to  contract  by  voluntary  effort.  For  a  very  long  time,  indeed, 
the  various  movements  are  capable  of  being  performed,  although 
with  much  diminished  power,  and  it  is  only  in  the  last 
stage  of  the  affection  that  complete  immobility  of  the  limb  is 
produced. 

At  times  the  loss  of  motor  power  apparently  much  exceeds 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  157 

the  loss  of  muscular  substance  ;  but  in  these  cases  the  bulk  of 
the  muscles  is  maintained  or  even  increased  by  an  interstitial 
fatty  hyperplasia,  while  the  individual  muscular  fibres  are 
atrophied,  so  that  the  disproportion  between  the  loss  of  mus- 
cular power  and  the  loss  of  muscular  substance  is  only  apparent 
and  not  real.  This  condition  will  be  more  fully  described  when 
the  closely-allied  disease  called  pseudo-hypertrophic  paralysis 
comes  under  consideration. 

The  reflex  'movements  are  occasionally  exaggerated,  but  this 
modification  is  not  constant  (Jaccoud). 

The  electrical  reaction  of  the  atrophied  muscles,  as  a  rule, 
corresponds  closely  with  the  diminished  volume  of  the  muscles 
and  the  loss  of  voluntary  power.  The  normal  faradic  contrac- 
tility is  maintained  until  the  muscle  has  undergone  a  high 
degree  of  atrophy,  and  it  is  only  in  the  last  stage  of  muscular 
atrophy  that  the  excitability  is  diminished  or  abolished.  It 
need  scarcely  be  added  that,  although  the  faradic  excitability  is 
not  diminished,  yet  the  energy  of  contraction  becomes  weaker 
and  weaker  in  proportion  as  the  contractile  elements  of  the 
muscle  disappear.  The  faradic  excitability  of  the  nerve-trunks 
is  retained  longer  than  that  of  the  muscle,  and  both  disappear 
some  time  before  complete  loss  of  voluntary  power  occurs. 
Galvanic  muscular  contractility  usually  remains  normal  for  a 
long  time,  although  the  energy  of  the  contraction  diminishes 
in  proportion  to  the  degree  of  atrophy,  so  that  stronger 
currents  are  required  to  produce  a  minimum  contraction 
(Eulenburg).  The  galvanic  excitability  of  the  nerve-trunks 
also  remains  unimpaired  for  a  long  time.  Rosenthal  has  directed 
attention  to  the  fact  that  the  nerve-trunks  behave  differently 
at  different  points  in  their  course,  so  that  while  electric  stimu- 
lation applied  to  a  portion  situated  near  the  centre  may  pro- 
duce normal  effects,  its  results  may  be  less  than  normal,  or 
entirely  wanting  when  a  more  peripheral  tract  is  stimulated. 
Slight  qualitative  changes  in  the  muscular  reaction  may  attend 
the  ultimate  stage  of  atrophy. 

Fibrillary  contractions  of  the  affected  muscles  are  fre- 
quently observed  during  the  entire  active  stage  of  the  disease. 
These  consist  of  vibratory  tremors  or  quivering  of  the  muscular 
fibres.     They  occur  spontaneously,  but  may  be  provoked  by 


158  SYSTEM   DISEASES   OF  THE 

gently  tapping  the  surface,  by  exposing  to  the  air  parts  which 
are  usually  covered,  by  electrical  excitation,  and  by  active  or 
passive  movements  of  the  affected  muscles.  These  j&brillary 
contractions  are  sometimes  the  earliest  symptoms  of  a  fresh 
advance  of  the  disease  into  parts  previously  unaffected,  and 
they  disappear  altogether  when  the  atrophy  has  reached  an 
extreme  degree,  or  when  its  progress  is  arrested  (Roberts), 

Occasionally  clonic  or  tonic  contractions  of  entire  muscles,  or 
groups  of  muscles,  may  occur,  accompanied  by  intense  pain, 
analogous  to  the  well-known  cramp  of  the  calf. 

The  sensibility,  as  a  rule,  is  entirely  unaffected.  In  some 
cases,  however,  the  atrophy  of  the  muscles  is  preceded  by 
paroxysms  of  pain  in  the  affected  parts.  At  times  the  pains 
follow  the  course  and  distribution  of  single  nerve  trunks,  as 
that  of  the  median  and  ulnar  nerves ;  but  at  other  times  the 
pains  appear  to  have  their  origin  in  the  sensory  nerves  of 
the  muscles.  In  the  latter  case  compression  of  the  affected 
muscles,  as  well  as  active  and  passive  movements  of  them,  pro- 
vokes or  aggravates  the  pain,  and  in  some  cases  the  electro- 
muscular  sensibility  seems  to  be  increased.  In  the  later  stages 
of  the  affection  a  moderate  degree  of  anaesthesia  may  be  present, 
especially  in  the  hands  and  tips  of  the  fingers,  in  the  form  of 
blunting  of  common  sensation.  The  farado-cutaneous  sensi- 
bility may  also  be  diminished,  and  complete  analgesia  of 
circumscribed  areas  is  not  uncommon.  Sensations  of  cold  and 
numbness  in  the  finger  tips,  formication,  and  other  sensations 
are  frequently  observed. 

Vaso-mofor  disturbances  of  various  degrees  and  extent  may 
occur  in  the  affected  regions.  In  the  beginning  the  temperature 
of  the  affected  extremities  is  increased.  Baerwinkel  found  an 
elevation  of  1°  in  one  case,  and  Frommann  found  in  the  side 
first  attacked  a  rise  of  0*2°  or  0'3°  C,  as  compared  with  the 
opposite  side.  In  more  advanced  stages  the  temperature  is 
not  raised,  and  at  a  still  later  period  a  distinct  lowering  occurs, 
which,  according  to  Rosenthal,  may  amount  to  4°  C,  and 
according  to  Jaccoud  to  3  or  4;°  C.  below  the  normal. 

The  affected  parts  are  cold  and  pale,  and  this  is  especially 
likely  to  be  the  case  in  the  hands.  This  local  ischsemia  is 
followed  by  relaxation  of  the  vessels,  and  consequent  warmth 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  159 

and  redness  of  the  affected  part.  An  excessive  sweating 
(hyperidrosis)  of  a  generalised  character  occurs  in  the  later 
stages  of  the  affection,  but  whether  this  is  due  to  vaso- motor 
disturbance  is  unknown  (Frommann,  Friedreich). 

Trophic  disturbances  occur  at  times  in  other  tissues  in  addi- 
tion to  the  muscular  affection.  The  skin  is  not  unfrequently 
implicated ;  and  in  these  cases  both  the  epidermis,  cutis,  and 
subcutaneous  tissues  are  affected.  The  affection  of  the  skin 
may  be  entirely  wanting,  and  scarcely  ever  reaches  a  high 
degree,  even  where  the  muscular  disease  is  far  advanced. 
Painful  swellings  of  the  joints  have  been  observed  in  the  early 
stages  of  the  disease  (Remak).  These  swellings  (arthritis 
nodosa)  generally  occur  in  the  phalangeal  joints,  and  are  in  ail 
probability  closely  related  to  the  arthropathies  of  tabes  dorsalis, 
except  that  the  latter  are  more  frequent  in  the  large  than  in 
the  small  joints. 

Oculo-pupillary  symptoms  are  on  rare  occasions  observed  in 
this  disease.  They  consist  of  flattening  of  the  cornea  (Voisin), 
and  contraction  and  sluggish  reaction  to  light  of  one  or  both 
pupils  (Voisin,  Baerwinkel,  Schneevogt,  Rosenthal).  These 
symptoms  are  in  all  probability  due  to  paralysis  of  the 
sympathetic  fibres  of  the  iris. 

In  the  early  stage  of  progressive  muscular  atrophy  the 
patient  may  complain  of  chills,  and  there  may  be  a  continuous, 
though  slight,  increase  of  temperature,  which  lasts  for  days  or 
months.  This  febrile  condition  may  sometimes  be  associated 
with  arthritis  nodosa,  and  may  probably  be  due  to  the  affection 
of  the  joints  (Remak).  In  the  later  stages  of  the  diseas^e 
transitory  or  permanent  elevations  of  temperature  may  occur, 
which  are  perhaps  due  to  such  complications  as  diseases  of 
the  lungs  or  acute  bed-sore.  No  constant  changes  have  been 
found  in  the  urine. 

§  413.  Course  and  Duration. — The  course  of  progressive 
muscular  atrophy  is  essentially  chronic.  It  may  at  times  be 
permanently  arrested  after  a  certain  group  of  muscles  is  de- 
stroyed, but  it  may  progress  steadily  until  nearly  all  the  voluntary 
muscles  are  implicated  and  the  unfortunate  patient  is  reduced 
to  such  utter  helplessness  that  he  cannot  raise  a  hand  to  feed 


160  SYSTEM  DISEASES   OF  THE 

himself  or  turn  himself  in  bed.  The  advance  of  the  disease  is 
seldom  continuous  even  when  it  is  progressive,  but  is  interrupted 
by  repeated  remissions.  These  may  extend  over  a  few  weeks, 
months,  or  years.  Dr.  Roberts  thinks  that  the  cases  caused 
by  over  exercise  of  the  muscles  nearly  always  terminated  in 
permanent  arrest  of  the  affection  after  the  destruction  of  one 
or  more  groups  of  muscles ;  while  cases  which  were  caused 
by  exposure  to  cold,  or  in  which  a  decided  hereditary 
predisposition  could  be  traced,  showed  a  greater  tendency  to 
a  progressive  course  and  a  fatal  termination.*  In  some  few 
cases  the  atrophied  muscles  may  by  treatment  be  restored  to 
their  former  bulk,  but  the  affected  muscles  usually  remain 
disabled  to  a  more  or  less  extent  for  the  remainder  of  life. 

The  duration  of  the  disease  is  very  variable  and  uncertain. 
In  twenty-eight  cases  analysed  by  Dr.  Roberts  the  mean  dura- 
tion was  thirty-eight  months;  of  these  four  cases  ended  in 
recovery,  their  mean  duration  being  fourteen  months ;  in 
thirteen  cases  the  disease  was  arrested  with  a  mean  duration 
of  twenty-seven  months,  and  the  remaining  eleven  cases  died 
with  a  mean  duration  of  the  disease  of  upwards  of  five  years. 

§  414.  Morbid  Anatomy. — The  essential  anatomical  changes 
found  on  post-mortem  examination  of  those  who  have  died 
from  progressive  muscular  atrophy  are  confined  to  the  muscles 
the  spinal  cord,  and  the  nerves. 

The  muscles  of  the  affected  regions  are  wasted  in  various 
degrees,  and  even  different  parts  of  the  same  muscle  may 
present  differences  in  the  degree  to  which  the  atrophy  has 
extended.  A  small  portion  of  an  affected  muscle  may,  indeed, 
retain  its  normal  bulk  and  appearance,  while  the  rest  is 
reduced  to  a  fibrous  band.  The  altered  muscles  are  generally 
of  a  pale  red  or  rose  colour,  while  at  other  times  they  may  be 
buff  or  ochre,  and  streaks  of  adipose  tissue  may  be  seen  to  run 
iu  lines  between  the  fibres. 

The   early    investigators    (Meryon,   Duchenne,   Cruveilhier, 

Wachsmuth,  and  Valentiner)  regarded  the  muscular  changes 

as  being  the  result  of  fatty  degeneration  of  the  fibres,  with 

secondary  disappearance  of  the  sarcolemma ;  but  the  labours  of 

*Eeynolds'  System  of  Medicine,  Art.  Wasting  Palsy,  vol.  ii.,  p.  172, 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  161 

recent  investigators  (Robin,  Friedberg,  Foerster,  Schueppel, 
Hay  era,  and  Friedreich)  have  shown  that  the  fatty  meta- 
morphosis of  the  primitive  fibres  is  a  secondary  result  of  a 
previous  inflammatory  change.  The  first  changes  begin  in  the 
perimysium  internum,  as  a  hyperplastic  growth  of  the  interstitial 
connective  tissue  in  its  finest  ramifications  among  the  single 
primitive  bundles.  Swelling  and  multiplication  of  the  muscular 
corpuscles,  along  with  proliferation  of  their  nuclei,  may  be 
observed,  and  at  times  parenchymatous  granular  cloudiness  of 
the  transverse  striped  fibrillary  substance.  Friedreich  says  that 
he  has  observed  hypertrophied  muscular  fibres  along  with  a 
dichotomous  or  trichotomous  division  of  their  fibres.  Wasting 
of  the  muscular  substance  goes  on  side  by  side  with  increase  of 
the  interstitial  tissue,  a  process  which  ultimately  leads  to  a 
fibrous  degeneration  or  true  cirrhosis  of  the  muscle.  A  develop- 
ment of  fat  may  take  place  within  the  hyperplastic  connective 
tissue,  leading  to  a  pseu do- hypertrophy  of  the  muscle. 

The  condition  of  the  spinal  cord  and  of  the  anterior  spinal 
nerve  roots  has  been  examined,  according  to  Eulenburg,  in 
forty-nine  cases,  and  out  of  these  positive  changes  have  been 
found  in  thirty-four,  while  in  fifteen  the  results  were  negative.  If, 
however,  the  special  methods  and  special  skill  which  are  required 
for  conducting  the  examination  of  the  spinal  cord  be  taken  into 
consideration,  too  much  weight  need  not  be  attached  to  the 
negative  statements.  In  the  hands  of  experts  in  the  present 
day  changes  are  almost  always  found  in  the  cord,  hence  the 
negative  results  of  the  older  observers  may  be  fairly  attributed 
to  defective  methods.  Cruveilhier  was  the  first  to  draw  atten- 
tion to  the  condition  of  the  anterior  roots  of  the  nerves  in 
this  disease.  In  the  body  of  the  showman,  Le  Compte,  who 
died  from  progressive  muscular  atrophy  of  five  years'  duration, 
he  found  that  the  anterior  roots,  especially  in  the  cervical  region, 
were  remarkably  small  as  compared  with  the  posterior  roots ; 
and  in  a  second  case,  observed  by  him,  a  similar  condition  was 
found.  In  these  cases  the  brain,  cord,  and  posterior  roots  were 
stated  to  be  normal.  Atrophy  of  the  anterior  spinal  roots, 
either  with  or  without  other  morbid  changes,  has  since  that 
time  been  found  by  various  competent  observers,  amongst 
whom  may  be  mentioned  Clarke,  Vulpian,  Luys,  Rosenthal, 
L 


162  SYSTEM   DISEASES-  OF   THE 

Hayem,  Charcot,  Joffroy,  Friedreich,  and  many  others.  The 
anterior  nerve  roots  have  in  some  cases  been  found  normal 
by  Clarke,  Frommann,  Gull,  Friedreich,  Tiirck,  Von  Reckling- 
hausen, Joffroy,  and  Frerichs.  It  may,  therefore,  be  concluded 
that  the  atrophy  of  the  anterior  roots  is  not  the  essential  morbid 
change,  Valentiner,  in  1855,  found  a  central  softening  of  the 
grey  matter  in  the  neighbourhood  of  the  lowest  cervical  and 
the  uppermost  dorsal  nerves;  and  Schneevogt  also  found  a 
softening  of  the  cord  from  the  fifth  cervical  to  the  second 
dorsal  nerves.  Frommann  observed  changes  in  the  anterior 
column  and  anterior  commissure  extending  from  the  medulla 
oblongata  downwards. 

Luys,  however,  was  the  first  to  direct  attention  to  the  morbid 
changes  in  the  grey  substance.  A  man,  the  subject  of  advanced 
atrophy  of  the  muscles  of  the  left  hand  and  forearm,  along  with 
slight  atrophy  of  the  muscles  of  the  right  hand,  having  died 
of  pneumonia,  the  spinal  cord  at  the  autopsy  appeared  healthy 
to  the  naked  eye,  but  microscopical  examination  showed  increase 
of  the  capillary  vessels  in  the  grey  substance  of  the  cervical 
enlargement.  The  walls  of  the  vessels  were  thickened  and  sur- 
rounded with  granular  exudation,  which  extended  into  the 
adjacent  tissues.  Many  corpora  amylacea  were  scattered 
.through  the  grey  substance.  A  considerable  number  of  the 
ganglion  cells  of  the  anterior  horns  had  disappeared  in  the 
part  affected,  and  were  replaced  by  granular  masses,  and  of  the 
remaining  cells  some  were  in  a  condition  of  degeneration,  of  a 
brownish  colour,  full  of  dark  granules,  and  destitute  of  pro- 
cesses. The  degeneration  affected  principally  the  left  anterior 
cornu,  corresponding  with  the  seat  of  the  muscular  atrophy. 
The  anterior  nerve  roots  on  the  left  side,  corresponding  to 
the  disease  in  the  anterior  horn,  were  atrophied.  Six  cases 
have  since  been  described  by  Lockhart  Clarke,  confirming,  in 
all  essential  respects,  the  observations  of  Luys ;  and  similar 
observations  have  been  made  by  Dum^nil,  Schueppel,  Hayem, 
Charcot,  and  Joffroy. 

In  a  case  described  by  Charcot  the  ganglion  cells  of  the  left 
anterior  grey  horn  {Fig.  167,  A)  could  still  be  distinguished, 
but  were  observed  to  be  in  an  advanced  stage  of  atrophy.  In 
the  right  anterior  grey  horn  {Fig.  167,  B),  however,  the  cells 


SPINAL   CORD  AND  MEDULLA  OBLONGATA. 


163 


could  only  be  distinguished  in  one  group — the  postero-lateral 
{Fig.  167,  h) — while  the  cells  of  the  remaining  groups  were 
completely  destroyed.  It  has  appeared  to  me,  however,  that 
too  little  attention  has  hitherto  been  paid  to  the  condition  of 


Fig.  167. 


Fig.  167  (Charcot).  Transverse  Section  of  the  Ceifical  Region  of  the  Spinal  Cord, 
from  a  case  of  progressive  muscular  atrophy. — A,  Left  anterior  grey  horn;  the 
ganglion  cells  have  persisted,  but  are  much  altered  in  appearance.  B,  Right 
anterior  grey  horn,  almost  complete  atrophy  of  the  cells,  one  group  only  (b) 
having  persisted. 

the  central  column.  In  the  annexed  diagram,  from  Charcot 
{Fig.  167),  the  central  column,  especially  the  left  one,  is  seen  to 
be  intersected  by  enlarged  vessels,  and  that  of  itself  affords 
some  evidence  that  this  column  was  not  free  from  disease  in  the 
section  from  which  the  drawing  was  taken.  It  seems  to  me, 
indeed,  that  the  morbid  process  begins  on  each  side  of  the 
central  canal,  probably  in  the  tissues  immediately  adjoining 
the  central  artery,  and  that  it  extends  outwards  and  forwards 
as  well  as  upwards  and  downwards  from  this  point  as  a  centre^ 
In  a  transverse  section  of  the  middle  of  the  cervical  enlargement 
in  my  possession,  from  an  advanced  case  of  progressive  muscular 
atrophy,  the  material  of  which  I  owe  to  the  kindness  of 
Dr.  Dreschfeld,  it  was   unmistakable   that   the    central   grey 


164 


SYSTEM  DISEASES  OF   THE 


column  was  more  severely  diseased  than  any  other  portion  of 
the  section.  The  central  column  was  traversed  by  enlarged 
vessels,  and  almost  all  structure  was  obliterated,  while  the 
various  groups  of  ganglion  cells  in  the  anterior  horns  were  dis- 
tinctly recognisable.  The  cells  of  the  median  area  were,  indeed, 
completely  destroyed,  so  that  not  a  trace  of  them  could  be  seen, 
and  a  large  number  of  the  marginal  cells  of  the  other  groups 
were  also  destroyed,  so  that  the  groups  themselves  were  separated 
by  unusually  large  spaces  which  were  destitute  of  cells  {Fig.  168) 
The  cells  of  the  centres  of  the  groups  were,  however,  distinctly 
recognisable,  although  all  of  them  were  observed  to  be  in  a 

Fig.  168. 


Fig.  168  (Young).  Transverse  Section  from  the  Middle  of  the  Cervical  Enlargement 
of  the  Spinal  Oord,  from  an  advanced  ease  of  progressive  muscular  atrophy. — 
cc,  Central  canal;  i.  Internal,  al,  Antero-lateral,  and  pi.  Postero-lateral 
groups  of  ganglion  cells. 


state  of  pigmentary  atrophy  {Fig.  144,  8).  I  have  also  observed 
in  one  of  my  sections  a  streak  of  degeneration  to  pass  along  the 
posterior  branch  of  the  central  artery  {Fig.  Ill,  1")  into  the 
substance  of  the  posterior  grey  horns,  and  this  may  explain  why 
analgesia  of  patches  of  the  skin  is  frequently  associated  with 


SPINAL   CORD   AND   MEDULLA   OBLONGATA. 


165 


progressive  muscular  atrophy.  In  the  accompanying  woodcut 
{Fig.  169),  borrowed  from  Leyden's  great  work  on  the  diseases 
of  the  spinal  cord,  it  may  also  be  distinctly  recognised  that  the 
diseased  portions  occupy  mainly  the  central  columns  of  the 
cord,  and  that  there  are  lateral  extensions  of  the  disease  towards 
the  anterior  grey  horns  and  between  the  groups  of  ganglion  cells. 

Fig.  169. 


Fig.  169  (From  Leyden).  Transverse  Section  of  the  Spinal  Cord  from  the  Middle  of 
the  Cervical  Enlargement,  showing  that  the  central  column  and  a  large  portion  of 
the  anterior  grey  horns  are  diseased. 

A  case  of  progressive  muscular  paralysis  has  been  recently 
described  by  Erb  and  Schultze,  in  which  the  erector  spinse 
throughout  their  entire  extent,  the  trapezius  on  both  sides,  the 
muscles  connected  with  the  shoulder  blades,  those  of  the  upper 
arm,  the  pectorals,  the  gluteal  muscles,  and  the  flexors  of  the 
legs  on  the  thighs  were  atrophied.  The  case,  indeed,  appears 
to  have  been,  so  far  as  the  distribution  of  the  paralysis  is  con- 
cerned, very  like  that  of  Charlotte  A ,  already  described.  The 

patient  died  from  an  attack  of  syncope,  but  without  any  trace 
of  bulbar  symptoms,  and  a  microscopical  examination  of  the 
spinal  cord  showed  that  the  most  pronounced  changes  were 
found  in  the  "  central  region  of  the  grey  substance."  It  is  also 
mentioned  that  in  the  lower  half  of  the  lumbar  and  cervical 
enlargements  the  ganglion  cells  had  disappeared  from  the 
median  (central)  group.     The  cells  of  the  other  groups  were 


166  SYSTEM  DISEASES  OF  THE 

degenerated.  The  whole  microscopical  report  of  the  case, 
indeed,  bears  out  the  idea  that  the  disease  began  in  the  central 
column,  and  extended  forwards  into  the  anterior  horns. 

The  nature  of  the  disease  in  the  cases  just  described  appears  to 
have  been  a  chronic  inflammation  of  the  grey  matter,  but  in 
another  series  of  cases  the  affection  of  the  grey  matter  is  caused 
in  a  different  way. 

In  the  annexed  woodcut  {Fig.  170),  borrowed  from  Leyden's 
work,  a  section  of  the  cervical  enlargement  of  the  spinal  cord, 
from  a  case  of  syringomyelia,  is  represented.  It  will  be  recog- 
nised that  the  destruction  of  the  ganglion  cells  of  the  anterior 
horns  takes  place  in  this  case  much  in  the  same  way  as  in  cases 
of  chronic  inflammation  already  described,  but  in  which  distinct 
cavities  are  not  observed.  It  is  indeed  doubtful  whether  any 
essential  difference  exists  between  the  two  classes  of  cases, 

Fig.  170. 


Fig,  170  (From  Leyden).  Transverse  Section  of  the  Spinal  Cord  from  the  Middle  of 
the  Cervical  Enlargement,  from  a  case  of  Syringomyelia,  showing  a  cavity  behind 
the  posterior  commissure,  and  destruction  of  a  large  portion  of  the  ganglion  cells 
of  the  anterior  grey  horns. 

inasmuch  as  the  cavities  probably  result  either  from  inflamma- 
tion of  the  tissue  of  the  central  grey  column  and  of  the  adjoin- 
ing white  substance,  or  of  the  walls  of  the  central  canal. 

In  a  case  observed  by  Sir  William  Gull,  a  considerable  dilata- 
tion of  the  spinal  canal  was  found  in  the  cervical  region,  between 
the  fifth  cervical  vertebra  and  the  origin  of  the  third  and  fourth 
dorsal  nerves.  The  cavity  was  full  of  serous  fluid,  and,  with  the 
exception  of  a  thin  layer  which  surrounded  it,  and  could  be 
stripped  off  like  a  membrane,  the  grey  substance  had  dis- 
appeared, while  the  white  substance  and  the  anterior  nerve 


SPINAL   CORD   AND  MEDULLA  OBLONGATA.  167 

roots  seemed  normal.  In  a  case  observed  by  Scbueppel,  the 
bydromyelia  extended  down  to  the  tenth  dorsal  vertebra. 
Grimm  also  found  considerable  enlargement  of  the  central 
cavity  at  the  expense  of  the  grey  substance,  the  latter  being 
flattened  by  pressure  to  a  ring-shaped  plate,  but  in  this  case 
the  cord  in  the  lower  cervical  and  upper  dorsal  regions  pre- 
sented a  fusiform  swelling,  caused  by  the  growth  of  a  medul- 
lary sarcoma.  In  the  latter  series  of  cases,  the  destruction  of 
the  ganglion  cells  appears  to  have  been  caused  indirectly  by 
the  pressure  of  the  fluid  which  had  distended  the  central  canal. 

The  result,  however,  in  both  series  of  cases,  is  the  same,  the 
ganglion  cells  being  destroyed.  Progressive  destruction  of  the 
cells  seems  then  to  be  the  essential  feature  of  the  morbid 
anatomy  of  the  disease.  It  is  right  to  add  that  some  competent 
observers  (Lichtheim)  found  the  anterior  grey  horns  normal, 
but  it  is  probable  that,  in  the  earlier  observations  at  least,  the 
changes  in  the  ganglion  cells  had  been  overlooked.  The  posterior 
columns,  the  posterior  horns,  the  posterior  roots,  and  the  inter- 
vertebral ganglia  have  been  found  in  a  state  of  degeneration, 
in  addition  to  the  affection  of  the  anterior  horns. 

Schneevogt  found  the  sympathetic  in  the  neck  diseased  in  a 
case  examined  by  him.  The  cervical  sympathetic  was  converted 
almost  into  a  fatty  cord,  in  which  the  nerve  fibres  were  pressed 
aside  by  fat  cells,  which  contained  beautiful  crystals.  The  cer- 
vical ganglia  were  almost  entirely  changed  into  fat  cells,  and 
the  thoracic  part  of  the  sympathetic  also  abounded  in  fat.  Two 
similar  observations  were  made  by  Jaccoud,  and  he  inferred 
from  the  appearances  present  that  the  disease  began  in  the 
sympathetic  and  spread  along  the  rami  communicantes  to  the 
cord  and  along  the  peripheral  nerves  to  the  muscles.  Changes 
in  the  sympathetic  have  been  found  by  Swarzenski  and  by 
Dam^nil ;  while  other  observers  as  Landry,  Frommann,  Hayem, 
Charcot  and  Joffroy,  and  Friedreich  have  found  the  sympa- 
the-tic  healthy. 

The  peripheral  nerves  distributed  to  the  affected  muscles 
have  also  been  found  affected  by  Schneevogt,  Trousseau, 
Virchow,  Freidberg,  Hayem,  Charcot  and  Joffroy,  Bamberger, 
Rosenthal,  Friedreich,  and  others.  The  degenerations  were 
sometimes  limited  to  the  finer  intra-muscular  nerve  branches, 


168  SYSTEM  DISEASES   OF  THE 

and  at  other  times  they  existed  in  the  large  nerve  trunks  and 
in  the  plexuses.  The  changes  observed  were  hyperplasia  of 
the  neurilemma,  multiplication  of  nuclei,  and  fibrillary  thicken- 
ing of  the  sheath  of  Schwann.  Friedreich  also  found  varicose 
dilatation  of  the  medullary  sheath  with  secondary  atrophy  of 
the  nerve  fibres.  In  some  few  cases  examination  of  the  peri- 
pheral nerves  gave  negative  results. 

§  415,  Morbid  Physiology. — Various  theories  have  from  time 
to  time  been  advanced  to  account  for  the  symptoms  of  progressive 
muscular  atrophy.  The  theory  of  Cruvielhier,  who  regarded 
atrophy  of  the  anterior  roots  as  the  essential  morbid  alteration,  as 
well  as  the  views  of  those  authors  who  believe  that  the  symptoms 
are  caused  by  disease  of  the  peripheral  nerves,  antero-lateral 
columns,  or  posterior  columns  of  the  cord,  is  definitely  abandoned 
by  all  pathologists  in  the  present  day.  The  theory  first  advanced 
by  Schneevogt,  and  afterwards  elaborated  by  Jaccoud,  which  at- 
tributes the  disease  to  a  morbid  change  of  the  sympathetic,  now 
reckons  only  few  adherents.  In  the  first  place,  the  sympathetic  is 
by  no  means  regularly  affected  in  progressive  muscular  atrophy ; 
and  when  it  is  implicated  the  morbid  change  is  declared  by  the 
superadded  symptoms,  which  may  be  briefly  summed  up  as 
oculo -pupillary  phenomena.  In  short,  the  disease  of  the  sym- 
pathetic is  an  occasional  concomitant  affection ;  and  in  these 
cases  the  morbid  changes  appear  to  be  propagated  from  the 
anterior  horns  along  the  rami  communicantes  to  the  cervical 
and  dorsal  portion  of  the  sympathetic  trunk  and  ganglia.  It 
is  not  impossible  that  a  reverse  process  may  take  place,  but 
even  in  that  case  the  disease  of  the  anterior  horns,  so  far  as 
the  nervous  system  is  concerned,  would  be  the  fundamental 
lesion  of  the  affection. 

These  theories  being  disposed  of,  two  only  remain — the 
myopathic  theory,  of  which  Friedreich  is  the  declared  champion, 
and  the  neuropathic  theory,  of  which  Charcot  may  be  mentioned 
as  the  most  prominent  advocate,  Aran  first  advanced  the  myo- 
pathic theory,  but  in  his  day  the  constant  changes  which  have 
since  been  found  in  the  nervous  apparatus  had  not  been  disco- 
vered. No  onedenies  the  reality  of  these  changes  at  present,  the 
only  question  which  arises  is  whether  the  muscular  alteration  pre- 


SPINAL  CORD   AND  MEDULLA   OBLONGATA.  169 

cedes  the  morbid  changes  in  the  cord,  or  whether  the  former  are 
secondary  to  and  caused  by  the  latter.  Progressive  muscular  atro- 
phy,according  to  Friedreich,  begins  as  a  primary  chronic  myositis 
The  intra-muscular  nerves  are  secondarily  implicated,  and  a 
chronic  neuritis  ascends  along  the  course  of  the  nerve  trunks 
to  their  roots.  The  neuritis  may  then  extend  in  the  cord  itself, 
producing  a  chronic  myelitis,  which  may  spread  in  various 
directions.  This  change  may  extend  to  the  anterior  cornua, 
but  the  nutrition  of  the  peripheral  nerve  fibres  and  of  the 
ganglion  cells  of  the  grey  anterior  cornua  of  the  cord  is  also 
affected  by  the  disturbed  motor  functions,  caused  by  the  disease 
in  the  muscles.  Various  objections  may  be  urged  against  this 
theory,  not  the  least  important  of  these  being  the  fact  that  the 
peripheral  nerves  and  anterior  nerve  roots  have  been  found 
quite  normal  in  a  considerable  number  of  cases. 

Friedreich  would  supplement  the  theory  of  neuritis  ascendens 
by  the  subordinate  theory  that  simple  suspension  of  muscular 
action  would  of  itself  cause  atrophy  of  the  ganglion  cells.  But 
the  changes  observed  in  the  anterior  horns  of  the  cord  in  the 
case  of  amputated  limbs  do  not  equal  in  severity  those  found 
in  progressive  muscular  atrophy.  This  theory  also  utterly  fails 
to  account  for  those  cases  in  which  the  destruction  of  the  grey 
matter  of  the  anterior  horns  is  produced  by  slow  compression 
from  gradual  distension  of  the  central  canal  by  fluid.  Various 
other  objections  might  be  urged  against  the  myopathic  theory, 
but  enough  has  been  said  to  show  that  it  at  least  presents 
wide  gaps  which  must  be  filled  up  before  it  can  be  considered 
established. 

The  neuropathic  theory  has  at  least  the  merit  of  being 
simple,  and  of  presenting  fewer  difiiculties.  According  to  it, 
the  atrophy  is  due  to  the  progressive  changes,  primarily  of  an 
irritative  character,  of  the  ganglion  cells  of  the  anterior  horns. 
Progressive  bulbar  paralysis,  which  is  so  frequently  associated 
with  progressive  muscular  atrophy,  is  an  analogous  affection 
caused  by  morbid  changes  in  the  groups  of  motor  cells  lying  in 
the  floor  of  the  fourth  ventricle,  the  reason  that  the  two  diseases 
are  so  frequently  associated  being  merely  that  the  morbid 
process  extends  from  the  anterior  horns  by  continuity  to  the 
motor  centres  in  the  floor  of  the  fourth  ventricle.     The  dis- 


170  SYSTEM  DISEASES   OF  THE 

tinction  between  the  two  diseases  is,  indeed,  dependent  upon  the 
locality  of  the  lesion  in  each  case.  In  both  these  diseases  the 
nature  of  the  lesion  which  destroys  the  ganglion  cells  is  of  little 
importance.  Much  the  same  results  (except  probably  in  respect 
to  the  rapidity  with  which  the  atrophy  is  developed)  follow 
ordinary  grey  degeneration,  chronic  induration,  myelitis,  red 
softening,  Clarke's  granular  degeneration,  or  isolated  pigmentary 
degeneration  of  the  cell  elements. 

On  the  supposition  that  the  disease  begins  in  the  central  grey 
column  and  extends  outwards  and  forwards  into  the  anterior  grey 
horns,  it  may  be  readily  explained  why  the  groups  of  muscles 
engaged  in  special  actions  are  usually  the  first  to  be  affected. 
We  have  already  seen  that  the  central  column  is  the  embryonic 
area  of  the  grey  substance,  and  that  the  median  area  of  the 
anterior  horns  in  the  lumbar  and  cervical  enlargements,  and  the 
medio-lateral  areas  in  the  dorsal  and  upper  cervical  regions  of 
the  cord,  may  be  regarded  as  outgrowths  of  the  central  column. 
The  median  and  medio-lateral  areas  will  consequently  be  the 
first  portions  of  the  anterior  horns  to  be  affected,  and  the  por- 
tions which  contain  the  fundamental  cells  will  be  the  last  to 
become  diseased.  When,  therefore,  the  lumbar  and  dorsal 
regions  of  the  cord  are  affected,  the  muscles  which  maintain  the 
erect  posture  in  man  will  be  those  most  liable  to  be  affected, 
as  will  be  more  fully  pointed  out  with  regard  to  pseudo-hyper- 
trophic  paralysis.  Again,  when  the  cervical  enlargement  is  the 
first  to  be  affected,  the  morbid  process  will  extend  more  readily 
forwards  to  the  median  area  than  in  any  other  direction,  and 
the  small  muscles  of  the  hand  will  be  first  affected.  It  will 
hereafter  be  pointed  out  that  when  the  medulla  oblongata  is 
first  affected  the  disease  begins  in  the  upward  continuation 
of  the  central  column,  and  that  the  accessory  nuclei  will  be 
liable  to  become  first  diseased ;  and  hence  it  is  that  the  com- 
plicated movements  of  articulation  are  generally  the  first  to  be 
affected. 

On  the  supposition  that  the  morbid  process  begins  in  the 
central  column,  it  may  also  be  readily  explained  why  muscles 
innervated  from  different  levels  of  the  cord  may  be  affected, 
while  muscles  innervated  from  the  intervening  portion  are 
spared,  without  our  being  obliged  to  assume  that  the  morbid 


SPINAL   CORD   AND   MEDULLA  OBLONGATA,  171 

process  in  the  cord  has  started  from  two  or  more  centres  of 
origin.  The  morbid  process  may,  for  instance,  extend  forwards 
into  the  median  area  in  the  cervical  enlargement,  while  it  may 
pass  upwards  through  the  upper  cervical  region  and  keep 
limited  to  the  immediate  neighbourhood  of  the  central  canal, 
where  it  would  produce  no  symptoms,  and  then  on  reaching 
the  medulla  oblongata  extend  to  the  accessory  nuclei,  and  thus 
produce  the  symptoms  of  bulbar  paralysis, 

§  416.  Diagnosis. — The  partial  form  of  the  disease  is  liable  to 
be  confounded  with  muscular  atrophy  caused  by  direct  mechanical 
injury  to  the  muscle,  or  with  the  various  diseases  of  the  peri- 
pheral nerves.  If  the  disease  remain  confined  to  the  muscles 
originally  affected,  or  to  the  region  of  a  single  nerve  trunk, 
progressive  muscular  atrophy  can  be  excluded;  and  muscular 
atrophy  resulting  from  disease  of  a  mixed  nerve  is  usually 
accompanied  by  loss  of  sensation. 

The  disease  may  also  be  confounded  with  lead  palsy ;  but  in 
the  latter  the  invasion  is  comparatively  sudden,  the  paralysis 
being  at  its  height  in  a  week  or  a  fortnight  at  most ;  while  the 
electric  contractility  is  diminished  or  lost  at  an  early  period. 
In  the  former  the  paralysis  precedes  the  atrophy ;  while  in 
the  latter  the  loss  of  muscular  power  is  almost  always  directly 
in  proportion  to  the  wasting  of  the  muscular  masses,  and  the 
electric  contractility  is  maintained  so  long  as  any  muscle  is 
preserved.  The  general  symptoms  which  characterise  lead 
poisoning  will  also  assist  the  diagnosis. 

Ordinary  general  paralysis  of  central  origin  may  be  distin- 
guished from  progressive  muscular  atrophy  by  the  fact  that  in 
the  former  the  paralysis  occurs  as  an  early  symptom,  and  it  is 
rare  that  the  muscular  emaciation  bears  any  proportion  to  the 
loss  of  power.  Progressive  muscular  atrophy  attacks  the  muscles 
in  separate  groups,  dissecting  out  either  individual  muscles  or 
groups  of  muscles  from  amongst  others  which  remain  healthy, 
and  does  not  attack  at  the  same  time  extensive  regions  or  the 
entire  body. 

The  diagnosis  between  progressive  muscular  atrophy  and 
infantile  paralysis  has  been  mentioned  already. 


172  SYSTEM  DISEASES   OF   THE 

§  417.  Prognosis. — Progressive  muscular  atrophy  is  always 
very  intractable,  and  when  the  muscles  of  the  trunk  are  invaded 
it  always  progresses  slowly  towards  a  fatal  termination.  In  the 
partial  forms,  when  the  disease  is  limited  to  one  or  two  ex- 
tremities, there  is  no  danger  to  life,  but  the  limbs  are,  as  a 
rule,  permanently  damaged.  In  many  cases  the  advance  of  the 
disease  may  be  checked,  and,  so  long  as  voluntary  motion  and 
the  electrical  reactions  are  not  completely  lost,  some  hope 
may  be  entertained  that  partial  restoration  of  the  affected 
muscles  may  take  place.  The  most  unfavourable  cases  are 
those  which  begin  in  a  multiple  form  and  spread  rapidly.  The 
cases  in  which  the  disease  begins  in  the  thorax  or  shoulder  are 
unfavourable,  because  the  affection  is  very  liable  to  implicate 
the  respiratory  muscles.  When  bulbar  symptoms  supervene 
the  prognosis  is  specially  unfavourable,  and  when  the  muscles 
of  respiration  are  invaded  a  fatal  termination  may  be  expected 
within  a  short  time.  When  the  disease  can  be  traced  back  to  a 
hereditary  predisposition  it  manifests  a  greater  tendency  to 
become  generalised,  and  consequently  the  prognosis  is  more 
unfavourable.  The  prognosis,  on  the  other  hand,  is  more 
favourable  when  the  affection  is  caused  by  overwork  and  when 
it  is  confined  to  the  hands  and  forearms. 

§  418.  Treatment. — An  attempt  must  first  be  made  to  remove 
the  cause.  When  the  disease,  for  instance,  is  caused  by  a  syphilitic 
taint  the  usual  antisyphilitic  treatment  must  be  adopted.  When 
overwork  of  the  affected  muscles  appears  to  have  been  the 
exciting  cause  of  the  disease,  they  must  be  allowed  to  rest. 
When  a  decided  hereditary  predisposition  to  the  affection  is 
manifested  in  a  family,  prophylactic  measures  may  be  employed, 
such  as  a  regulated  course  of  gymnastics.  The  members  of 
such  families  should  also  be  shielded  from  deleterious  influ- 
ences, especially  those  which  are  known  to  excite  the  disease. 

The  direct  treatment  of  the  established  disease  embraces  the 
employment  of  hygienic  measures,  such  as  baths,  methodical 
exercise,  change  of  air  and  good  diet,  and  the  employment  of 
galvanism  and  friction  to  the  affected  muscles.  No  medicine 
has  hitherto  been  found  of  any  use  in  the  treatment  of  this 
disease.     Tonics,  as  iron  and  quinine,  may  be  useful  adjuncts  in 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  173 

the  treatment,  and  the  nitrate  of  silver,  arsenic,  phosphorus, 
and  iodide  of  potassium  have  been  employed,  but  with  doubtful 
success. 

Thermal  and  sulphur  baths  have  been  recommended,  and  the 
waters  of  Aix-la-Chapelle  have  been  much  praised,  but  appa- 
rently on  insufficient  evidence.  The  cold  water  cure,  conducted 
in  a  good  hydropathic  establishment,  may  occasionally  be  found 
useful. 

Galvanism  is  undoubtedly  the  most  efficient  remedy  for  the 
disease.  The  local  use  of  the  faradic  current  was  applied  by 
Duchenne,  who  obtained  favourable  results  from  it,  but  the 
galvanic  is  probably  more  efficient  than  the  faradic  current. 
The  local  use  of  both  currents  alternately  has  given  good  results. 
When  the  muscular  excitability  is  very  low,  strong  currents  are 
required,  and  their  effects  should  be  intensified  by  inter- 
ruptions and  reversals,  but  as  the  excitability  returns,  weaker 
currents  should  be  employed,  I  have  observed  favourable 
results  from  the  use  of  electric  acupuncture.  Suitable  gym- 
nastics, to  call  forth  the  activity  of  the  affected  muscles,  passive 
motion,  shampooing,  and  friction,  are  all  useful  in  the  treat- 
ment of  the  disease.  When  the  muscular  atrophy  is  associated 
with  neuralgia  the  subcutaneous  injection  of  morphia  may  be 
employed.  Dr.  Roberts  recommends  an  injection  to  be  given 
in  the  morning,  and  he  states  that  it  often  enables  the  patient 
to  pursue  his  employment  with  comfort  during  the  day. 


4.  Primary  Lahio-Glosso- Laryngeal  Paralysis. 

{Chronic  Progressive  Bulbar  Paralysis.— Wa,chsmnih.) 

§  419.  Definition. — Labio-glosso-laryngeal  paralysis  consists 
of  a  progressive  paralysis  and  atrophy  of  the  muscles  of  the 
tongue,  lips,  soft  palate,  pharynx,  and  larynx. 

§  420.  History. — A.  brief  report  of  a  case  of  this  affection  was  sent  to 
Sir  Charles  Bell  in  1825  by  Dr.  F.  W.  Robinson,  and  Trousseau  wrote  an 
accurate  account  of  the  symptoms  of  the  affection  in  1841,  but  did  not 
publish  his  observations.  The  individuality  of  the  disease  was,  however, 
not  distinctly  recognised  until  1861,  when  Duchenne  described  the  affection 
with  his  usual  exhaustiveness  and  thoroughness. 


174  SYSTEM  DISEASES   OF  THE 

§  421.  Etiology. — It  does  not  appear  that  heredity  exercises 
any  influence  in  the  production  of  labio-glosso-lary ngeal  paralysis. 
It  occurs  most  frequently  between  the  fortieth  and  seventieth 
years  of  age,  and  only  exceptionally  before  the  fortieth  year. 
Tlie  disease  attacks  men  more  frequently  than  women,  the 
proportion  being  two  of  the  former  to  one  of  the  latter  (Dowse). 
All  ranks  of  society  from  the  highest  to  the  lowest,  and  every 
profession,  appear  to  be  liable  to  the  affection. 

Of  the  exciting  causes,  the  most  frequently  mentioned  are 
exposure  to  cold,  traumatic  influences,  as  a  blow  on  the  back  of 
the  neck,  violent  and  continuous  mental  excitement,  excessive 
mental  activity,  straining  of  the  muscles  affected,  as  in  singing 
and  speaking,  and  bad  and  insufficient  food.  Syphilis  is  not 
an  unfrequent  cause  of  the  disease ;  but  the  authors  who  regard 
this  affection  as  being  almost  always  of  syphilitic  origin  are 
undoubtedly  in  error. 

§  422.  Symptoms. — Slight  premonitory  symptoms  usually 
precede  the  full  development  of  the  disease,  but  they  are  often 
entirely  wanting  and  are  not  in  any  way  characteristic  of  the 
affection.  These  consist  of  pain  in  the  head  and  back  of  the 
neck,  slight  dizziness,  and  great  diminution  or  complete  loss 
of  the  reflex  irritability  of  the  larynx,  oesophagus,  and  pharynx. 
The  reflex  insensibility  of  the  mucous  membrane  of  the  fauces, 
epiglottis,  and  pharynx  is  sometimes  so  great  as  to  lead  to  a 
certain  amount  of  dysphagia,  and  the  passage  of  food  into  the 
larynx  for  a  considerable  time  before  any  actual  paralysis  is 
observed  (Krishaber). 

The  disease  may  begin  suddenly  with  difliculty  in  the  move- 
ments of  the  tongue  and  lips,  and  of  deglutition ;  but  in  these 
cases  it  is  probable  that  a  slight  hsemorrhage  has  occurred  in 
the  medulla,  and  consequently  they  cannot  be  regarded  as  true 
instances  of  the  primary  disease. 

The  symptoms  of  the  true  progressive  disease  creep  on 
o-radually  and  stealthily.  A  slight  affection  of  speech  is  usually 
the  first  symptom  to  attract  attention.  Utterance  is  less  distinct, 
the  pronunciation  of  certain  letters  presents  special  difliculty, 
and  the  tongue  and  lips  are  soon  fatigued,  so  that  prolonged 
reading  aloud  or  speaking  is  impossible. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  175 

This  is  followed  by  a  gradual  weakness  in  the  lips  and  palate. 
The  expression  of  the  face  is  altered,  the  voice  becomes  nasal, 
and  fatigue  of  the  muscles  of  mastication  and  deglutition  is 
readily  induced,  so  that  the  patient  is  soon  compelled  to  eat 
only  pulpy  food,  and  is  unable  to  swallow  much  at  one  meal. 

The  paralytic  symptoms  may  at  times  begin  in  the  lips  and 
palate  instead  of  the  tongue,  and  then  the  order  of  succession 
of  the  symptoms  will  differ  to  some  extent  from  that  just 
described. 

The  initial  period  of  debility  and  fatigue  of  the  affected 
muscles  may  extend  over  a  period  of  years  before  the  stage  of 
distinct  paralysis  is  reached.  When  once  distinct  paralysis  is 
established,  the  disease  assumes  a  more  progressive  character, 
and  advances  steadily  and  surely  to  a  fatal  termination. 

When  the  affection  begins  in  the  tongue,  the  patient  expe- 
riences an  ever-increasing  difficulty  in  pronouncing  the  dental 
and  guttural  sounds  which  are  respectively  produced  by 
approximation  of  the  tongue  to  the  teeth  or  hard  palate,  and 
of  the  root  of  the  organ  to  the  soft  palate.  Since  the  vowel  i 
require^  the  greatest  raising  of  the  tongue  for  its  production, 
its  pronunciation  is  the  first  to  suffer;  and  then  the  pronuncia- 
tion of  the  consonants  r,  s,  1,  k,  g,  t,  and  lastly  d  and  n,  becomes 
difficult,  imperfect,  and  finally  impossible. 

After  a  time  the  patient  is  unable  to  effect  the  coarser  and 
least  complicated  lingual  movements.  He  may  at  first  be  able 
to  protrude  the  tongue,  but  not  to  raise  the  tip  towards  the 
hard  palate  or  towards  the  nose  after  protrusion;  while  ina- 
bility to  move  the  tip  laterally  indicates  a  still  greater  degree 
of  paralysis.  As  the  paralysis  increases  the  tongue  cannot  be 
lengthened  into  a  point,  or  made  hollow  in  the  centre;  and, 
finally,  protrusion  is  impossible,  and  the  organ  lies  behind  the 
lower  row  of  teeth  completely  helpless  and  motionless,  or  main- 
tained in  constant  vibration  with  fibrillary  twitchings. 

The  tongue  may  maintain  its  normal  aspect,  or  become  large 
and  flabby;  but  much  more  frequently  it  is  sodden,  grooved 
longitudinally,  wrinkled,  and  shrunken,  while  simultaneous 
atrophy  of  the  papillae  gives  to  the  surface  a  glazed  ap- 
pearance. 

At  an  early  stage  of  the  affection  deglutition  is  rendered 


176  SYSTEM   DISEASES   OF  THE 

difficult,  simply  by  the  increasing  weakness  of  the  tongue. 
Great  difficulty  is  experienced  in  collecting  the  food  in  the 
mouth  so  as  to  form  it  into  a  bolus,  and  in  pressing  it  back 
against  the  soft  palate  and  into  the  pharynx ;  and  the  patient 
adopts  various  devices  in  order  to  supplement  the  deficiencies 
of  the  first  stage  of  deglutition.  He  takes  care,  as  Trousseau 
remarks,  to  chew  well  what  he  eats,  and  to  facilitate  its  gliding 
down  by  drinking  and  throwing  his  head  backwards,  while  at 
other  times  he  assists  the  imperfect  movements  of  the  tongue 
with  his  fingers,  using  them  to  extract  the  food  which  has 
lodged  between  the  teeth  and  cheeks,  and  to  push  the  bolus  to 
the  back  of  the  tongue  till  it  is  caught  by  the  reflex  move- 
ments of  deglutition. 

The  muscles  which  pass  from  the  inferior  maxilla  to  the 
hyoid  bone,  and  which  elevate  the  larynx  as  well  as  the  base  of 
the  tongue  during  deglutition,  are  implicated  in  the  paralysis 
along  with  the  intrinsic  muscles  of  the  tongue ;  hence  it  may 
be  observed  that  the  larynx  does  not  rise  so  readily  as  in  health 
during  the  second  stage  of  deglutition.  The  root  of  the  tongue 
cannot,  therefore,  be  brought  during  deglutition  over  the  de- 
pressed epiglottis,  the  glottis  is  not  completely  closed,  particles 
of  food  and  fluids  easily  find  their  way  into  the  trachsea,  and 
cause  distressing  paroxysms  of  cough  and  dyspnoea. 

The  saliva  cannot  be  swallowed  and  accumulates  in  the 
mouth,  and  owing  to  the  advancing  paralysis  of  the  orbicularis 
oris  flows  from  it  in  an  almost  continuous  stream.  Of  the 
muscles  innervated  by  the  facial  nerve  the  orbicularis  oris  is  the 
first  to  suffer.  With  the  increasing  weakness  of  this  muscle 
the  patient  becomes  unable  to  whistle,  blow,  compress  his  lips, 
or  kiss.  The  patient  experiences  difficulty  in  pronouncing  the 
vowels  o  and  u  ;  and  with  the  advance  of  the  paralysis  the  labial 
consonants  p,  f,  b,  and  m,  become  increasingly  difficult  to 
articulate. 

Paralysis  of  the  palate  renders  the  formation  of  the  explosive 
labial  consonants  still  more  difficult;  since  the  current  of  air 
necessary  to  force  the  lips  suddenly  asunder  escapes  through 
the  nose,  and  the  consonants  p  and  b  are  consequently  turned 
into  me  and  ve.  Duchenne  has  shown  that  if  the  patient's  nose 
be  closed  these  letters  are  much  better  pronounced.     Paralysis 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  177 

of  the  palate  also  gives  a  nasal  resonance  to  the  voice,  and 
permits  food  and  fluids  to  escape  readily  through  the  nose 
during  efforts  at  deglutition.  When  the  muscles  of  the  tongue, 
lips,  and  palate  are  simultaneously  paralysed,  speech  becomes 
more  and  more  indistinct,  and  the  patient  can  only  give  utter- 
ance to  inarticulate  and  grunting  sounds.  The  vowel  a,  how- 
ever, can  still  be  pronounced,  inasmuch  as  it  is  a  purely 
laryngeal  sound,  and  quite  independent  of  the  articulatory 
movements  of  the  tongue  and  lips. 

But  although  the  orbicularis  oris  suffers  more  profoundly 
than  the  other  facial  muscles,  the  quadratus  and  levator  menti 
are  more  or  less  implicated  in  the  paralysis.  The  muscles  of 
the  palpebral  and  nasal  regions  are  never  affected,  and  even  the 
elevators  of  the  superior  lip,  as  well  as  the  levator  menti  and 
buccinators,  are  only  on  rare  occasions  involved  in  the  paralysis. 
The  paralysed  muscles  are  almost  always  distinctly  atrophied, 
so  that  the  lips  look  thin,  sharp  edged,  and  furrowed,  and  fribril- 
lary  contractions  are  not  unfrequently  observed  in  them.  The 
patient  now  presents  a  very  striking  and  characteristic  appear- 
ance. The  lower  lip  hangs  loose  and  pendulous,  the  mouth 
cannot  be  closed,  it  is  somewhat  increased  in  breadth,  and  the 
naso-labial  folds  become  marked,  and  give  to  the  patient  a 
lachrymose  expression.  During  states  of  emotional  excitement 
the  lower  part  of  the  face  remains  comparatively  motionless, 
and  contrasts  strongly  with  the  vivacious  movements  of  the 
upper  half  of  the  face,  and  with  the  brightness  and  activity 
of  the  eyes. 

The  saliva  now  flows  from  the  mouth  in  a  continuous  stream, 
and  causes  much  annoyance  to  the  patient,  inasmuch  as  it  soaks 
through  the  pillow  at  night  and  requires  to  be  constantly  wiped 
from  the  lips  with  a  handkerchief  during  the  day.  The  saliva 
appears  to  be  secreted  as  a  rule  in  normal  quantity,  but  in 
some  cases  the  amount  of  secretion  is  very  largely  increased. 
Schulz  estimated  in  one  case  that  the  secretion  was  six  or  eight 
times  the  normal  amount,  and  Kayser  found  that  he  coujd 
increase  the  flow  by  reflex  irritation,  and  arrest  it  temporarily 
by  means  of  atropine. 

Mastication,  as  already  mentioned,  is  impaired  at  an  early 
stage  of  the  affection  from  the  difficulty  of  moving  the  tongue, 
M 


178  SYSTEM  DISEASES   OF  THE 

and  the  condition  becomes  aggravated  when  the  lips  and  buc- 
cinators are  simultaneously  paralysed.  But  the  difficulty  of 
mastication  is  greatly  augmented  when  the  motor  division  of 
the  trigeminus  is  involved  in  the  disease.  The  pterygoid 
muscles  are  usually  the  first  of  the  masticatory  muscles  to  be 
affected,  and  paralysis  of  them  abolishes  the  power  of  effecting 
the  lateral  movements  of  the  lower  jaw.  With  the  advancing 
paralysis  of  the  remaining  muscles  of  mastication,  the  power  of 
chewing  the  food  becomes  increasingly  difficult,  feeble,  and 
finally  impossible. 

The  difficulty  of  deglutition,  caused  by  paralysis  of  the 
tongue,  lips,  and  soft  palate,  is  greatly  augmented  when  the 
pharyngeal  muscles  and  those  which  close  the  larynx  are  in- 
volved in  the  disease.  When  the  pharyngeal  muscles  are 
paralysed  particles  of  food  are  apt  to  lodge  in  the  pharynx,  and 
this  increases  the  risk  of  foreign  particles  entering  the  larynx. 
At  other  times  the  whole  bolus  gets  fast  on  a  level  with  the 
glottis,  causing  danger  of  instant  suffocation. 

But  when  the  muscles  which  close  the  glottis  are  paralysed, 
the  danger  of  swallowing  either  solids  or  fluids  becomes  greatly 
intensified.  Particles  of  food  passing  into  the  larynx  produce 
distressing  paroxysms  of  coughing  and  dyspnoea,  and  by  passing 
into  the  bronchi  often  cause  pneumonia.  When  the  paralysis 
extends  to  the  oesophagus  deglutition  becomes  impossible,  and 
to  survive  the  patient  must  be  fed  by  the  stomach  pump.  When 
the  nucleus  of  the  spinal  accessory  nerve  is  involved  in  the 
disease  the  laryngoscope  reveals  paresis  or  paralysis  of  the  vocal 
cords,  the  voice  becomes  hoarse  and  feeble,  until  finally  there  is 
complete  aphonia.  The  power,  not  of  articulation  only,  but  of 
phonation  also,  is  now  abolished,  the  loss  of  this  function  being 
manifested  by  inability  to  pronounce  the  vowel  a.  The  loss 
of  phonation  does  not  necessarily  interfere  with  the  respiratory 
functions,  but  as  the  disease  advances  disorders  of  respiration 
and  circulation  supervene,  which  soon  prove  fatal. 

Not  much  is  known  with  respect  to  disorders  of  the  circula- 
tion in  the  early  stages  of  the  affection.  There  is  no  trustworthy 
record  of  retardation  of  the  pulse  which  could  with  probability 
be  referred  to  irritation  of  the  vagus,  but  a  pulse  rising  before 
death  from  130  to  150,  or  even  higher  per  minute,  has  been 


SPINAL   CORD    AND   MEDULLA   OBLONGATA.  179 

frequently  recorded,  and  is  probably  caused  by  paralysis  of  the 
vagus.  In  the  terminal  period  of  the  disease  patients  often 
suffer  from  fainting  fits,  accompanied  by  great  anxiety  and  a 
sensation  of  impending  death,  and,  indeed,  death  may  result 
from  an  attack  of  syncope.  These  phenomena  are  probably 
caused  by  the  cardiac  centres  of  innervation  having  become 
involved  in  the  disease. 

When  the  respiratory  mechanism  is  affected  a  fatal  termi- 
nation is  near.  The  respiratory  movements  become  feeble,  and, 
owing  to  the  implication  of  the  spinal  accessory  nerves,  the 
auxiliary  muscles  of  respiration  are  paralysed,  and  superior 
thoracic  breathing  is  impossible.  The  inefficiency  of  the  respi- 
ratory movements  renders  the  breathing  shallow,  and  all 
attempts  at  coughing  or  blowing  the  nose  are  weak  and 
powerless.  Patients  complain  of  a  feeling  of  constriction, 
accompanied  by  an  oppressive  feeling  of  want  of  breath. 
After  a  time  the  pneumogastric  nerve  appears  to  become  im- 
plicated in  the  disease.  Paroxysms  of  dyspnoea,  with  a  tendency 
to  syncope,  supervene,  but  these  must  not  be  confounded  with 
the  suffocative  attacks  which  occur  at  an  early  period  from  the 
accidental  introduction  of  foreign  bodies  into  the  larynx.  The 
attacks  of  dyspnoea  become  more  and  more  frequent  as  the 
disease  progresses,  and  the  breathing  power  feebler  and  feebler, 
until  ultimately  the  patient  dies  from  asphyxia.  Death  may, 
indeed,  be  caused  at  an  early  period  of  the  affection  by  a  slight 
disease  of  the  respiratory  organs,  such  as  a  bronchial  catarrh 
or  pneumonia. 

Atrophy  of  the  paralysed  muscles  is  one  of  the  most  constant 
and  striking  symptoms  of  this  affection.  It  is  usually  most 
marked  in  the  tongue,  and  the  lips  also  become  emaciated  and 
thin,  and  both  are  often  kept  in  constant  movement  by  fibrillary 
contractions.  Atrophy  of  the  soft  palate  has  not  yet  been 
recorded,  and  cannot  probably  be  recognised  with  certainty. 

Atrophy  of  the  paralysed  muscles  is  not  an  early  symptom  of 
the  disease,  and  does  not  run  a  parallel  course  with  the  paralysis. 
The  tongue  may,  however,  retain  a  normal  appearance  and 
volume,  and  yet  exhibit,  on  microscopical  examination,  exten- 
sive degeneration  of  its  muscular  fibres  (Charcot). 

Local  atrophy  and  fibrillary  contractions  of  the  small  muscles 


180  SYSTEM  DISEASES   OF  THE 

of  the  hand  are  sometimes  observed  iodicating  a  complication 
with  progressive  muscular  atrophy. 

The  electric  excitability  is  generally  said  not  to  undergo  any 
noteworthy  changes,  but  Erb  states  that  he  found  the  most 
marked  "  reaction  of  degeneration"  on  direct  irritation  of  the 
muscles  of  the  chin,  lips,  and  tongue.  The  electric  irritability 
of  the  nerves  was,  however,  normal,  or  but  slightly  diminished. 

The  sensibility  remains,  as  a  rule,  unaffected  throughout  the 
whole  course  of  the  disease,  and  even  taste  is  only  altered  on 
rare  occasions.  Affections  of  the  auditory  nerve,  consisting  of 
buzzing  of  the  ears  and  deafness,  have  occasionally  been 
observed.  The  trigeminus  is  sometimes  implicated,  the 
symptoms  observed  being  a  furry  feeling  and  anaesthesia  on 
both  sides  of  the  face,  and  want  of  common  sensation  in  the 
tongue,  and  in  some  cases  pain  has  been  felt  in  the  occipital 
and  upper  part  of  the  cervical  region  (Trousseau). 

The  intelligence  remains  quite  clear  to  the  last,  the  temper 
is  somewhat  excitable,  and  patients  often  manifest  an  inclina- 
tion to  laugh  on  slight  provocation. 

Reflex  irritability  is,  as  already  mentioned,  sometimes 
greatly  diminished  or  abolished  in  the  tongue,  soft  palate, 
pharynx,  and  even  in  the  larynx  before  the  appearance  of  any 
other  symptoms,  but  on  the  other  hand  it  is  often  retained  in 
these  parts  until  a  late  period  of  the  disease.  Even  when  the 
reflex  irritability  is  lost  the  patient  can  feel  and  localise  each 
touch  quite  distinctly. 

Vaso-motor  disturbances  have  not  been  recorded,  and  there 
is  no  fever  during  the  whole  course  of  the  disease. 

General  nutritive  disorders  occur  sooner  or  later  in  the 
course  of  the  affection.  These  are  in  large  part  due  to  the 
insufficient  quantity  of  food  taken,  and  which  ultimately  pro- 
duces a  state  of  inanition.  The  helplessness  of  the  patient  is 
greatly  aggravated  by  his  inability  to  close  the  glottis,  and 
thus  all  forcible  expiratory  actions  are  rendered  impossible. 
Duchenne  thought,  probably  on  insafficient  grounds,  that  the 
constant  loss  of  the  saliva  exercised  a  deleterious  influence  on 
digestion,  and  consequently  contributed  to  produce  the  general 
debility.  But  whatever  may  be  the  causes  which  co-operate  to 
produce  the  state  of  emaciation  and  marasmus  into  which  the 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  181 

patient  falls,  the  debility  at  last  becomes  so  great  that  he  is 
unable  to  get  up.  He  sits  in  bed,  with  the  upper  part  of  the 
body  propped  up,  and  with  the  head  resting  on  pillows  and 
inclined  to  one  side,  in  order  to  let  the  saliva  flow  out  of  the 
mouth,  and  death  soon  supervenes,  either  during  a  paroxysm  of 
dyspnoea  or  suddenly  and  quietly  from  arrest  of  the  heart's 
action. 

§  423.  Course,  Duration,  and  Ten'minations. — The  course  of 
bulbar  paralysis  is  always  slow  and  chronic, but  surely  progressive. 
There  is  seldom  a  remission  of  long  duration ;  any  degree  of 
improvement  is  still  rarer,  and  recovery  has  never  been  observed 
when  the  diagnosis  of  a  primary  affection  was  beyond  question. 
Death  usually  results  in  from  one  to  five  years. 

§  424.  Co'mplications. — Progressive  muscular  atrophy  is  the 
most  important  and  frequent  complication  of  bulbar  paralysis. 
Labio-glosso-laryngeal  paralysis  may  either  be  the  primary  affec- 
tion, or  it  may  merely  be  a  terminal  phenomenon  supervening  in 
the  course  of  progressive  muscular  atrophy,  and  caused  by  exten- 
sion of  the  morbid  process  in  the  anterior  grey  horns  of  the  cord 
to  the  motor  nuclei  of  the  medulla.  The  two  affections  are 
indeed  essentially  the  same  disease,  both  as  regards  the  clinical 
symptoms  and  the  anatomical  changes  found  after  death. 

Anhyotrophic  lateral  sclerosis  is  another  important  com- 
plication of  progressive  bulbar  paralysis,  and  the  latter  may 
either  be  the  primary  or  secondary  affection.  Amyotrophic 
lateral  sclerosis  occurs  not  unfreq;uently  in  the  later  stages  of 
bulbar  paralysis.  The  disease  is  then  characterised  by  the 
symptoms  of  progressive  muscular  atrophy  in  the  superior  and 
those  of  spastic  spinal  paralysis  in  the  inferior  extremities.  A 
number  of  cases  described  as  bulbar  paralysis  or  progressive 
muscular  atrophy  belong  to  this  class.  The  disease  is  no  doubt 
due  to  extension  of  the  morbid  process  in  the  medulla  to  the 
anterior  grey  horns  of  the  cervical  enlargement  and  to  the 
antero-laterai  columns  of  the  cord. 

§  425.  Morbid  Anatomy. — The  first  observations  with  respect 
to  the  morbid  alterations  of  the  nervous  system  were  conducted 


182  SYSTEM   DISEASES   OF  THE 

without  careful  microscopical  examination  of  the  medulla  and 
pons.  In  a  complex  case  of  paralysis  of  the  tongue,  lips,  and 
veil  of  the  palate,  combined  with  general  muscular  atrophy, 
recorded  by  Dr.  Dumenil,  the  roots  of  the  hypoglossal,  facial, 
and  spinal  accessory  nerves,  as  well  as  the  anterior  spinal  roots, 
were  found  wasted,  the  atrophy  also  extending  to  the  trunks 
of  the  nerves  themselves.  Trousseau  found  increased  consis- 
tency of  the  medulla  oblongata  and  thickening  of  the  dura 
mater  of  the  medulla ;  but  he  regarded  the  atrophy  of  the  roots 
of  the  bulbar  nerves  as  the  essential  morbid  alteration  in  this 
disease. 

The  close  anatomical  connection  which  the  researches  of 
Lockhart  Clarke  and  others  have  proved  to  exist  between  the 
nuclei  of  origin  of  the  nerves  implicated  in  this  disease,  as  well 
as  the  discovery  which  had  already  been  made  that  the  allied 
affections  of  progressive  muscular  atrophy  and  infantile  spinal 
paralysis  were  due  to  disease  of  the  ganglion  cells  of  the  ante- 
rior grey  horns  of  the  cord,  had  led  pathologists  to  suspect  that 
the  essential  anatomical  changes  in  this  disease  would  be  found, 
not  in  the  roots  of  the  nerves,  but  in  the  ganglion  cells  of  their 
nuclei  of  origin.  It  was  in  reference  to  this  expectation  that 
Dr.  Wilks  wrote :  "  The  anatomist  and  the  physiologist  have 
in  fact  informed  the  clinical  physician  of  the  precise  spot 
which  is  affected,  and  it  only  remains  for  the  pathologist  to 
prove  it," 

About  the  time  that  this  sentence  was  being  uttered  by  Dr. 
Wilks  the  opportunity  for  making  the  necessary  verification 
of  the  hypothesis  presented  itself  to  the  ever-vigilant  eye  of 
Charcot,  and  his  observation  was  soon  afterwards  confirmed  by 
Duchenne  and  Joffroy.  The  essential  anatomical  changes  in 
the  affection  appear  to  consist  of  a  degenerative  atrophy  of  the 
ganglion  cells  in  the  grey  nuclei  on  the  floor  of  the  fourth 
ventricle.  The  cells  shrink  and  become  filled  with  yellow  or 
brown  pigment,  their  nuclei  disappear,  and  finally  the  cells 
themselves  are  only  represented  by  angular,  glistening  pig- 
mented masses. 

In  some  cases  the  surrounding  tissue  was  found  to  contain 
corpuscles  of  Gluge  in  varying  quantity,  increase  of  connective 
tissue  and  in  the  number  of  nuclei  and  of  Deiter's  cells,  and 


SPINAL    CORD   AND   MEDULLA  OBLONGATA.  183 

hypertrophy  and  fatty  degeneration  of  the  vascular  walls.  The 
nerve  fibres  themselves  were  found  atrophied,  the  medullary 
sheath  had  disappeared,  and  in  chronic  cases  the  axis  cylinders 
also. 

The  nucleus  of  the  hypoglossal  nerve  appears  to  be  the 
starting  point  of  the  disease,  and  the  nuclei  of  the  spinal 
accessory  and  vagus  are  next  attacked,  while  the  disease  does 
not  extend  in  all  cases  to  the  nucleus  of  the  glosso-pharyngeal 

Fig.  171. 


NH -  , NH 


Fig.  171  (From  Leyden).  Portion  of  the  Orey  Substance  on  the  floor  of  the  fourth 
ventricle  on  a  level  with  the  middle  of  the  Hypoglossal  Nucleus,  from  a  case  of 
Progressive  Muscular  Atrophy  with  Bulbar  Paralysis,  showing  the  destruction  of 
the  Ganglion  Cells  of  the  nuclei  of  the  Hypoglossal  and  Pneumogastric  Nerves  (NH/. 
B,  Median  raphe ;  H,  H,  Fibres  of  the  hypoglossal  nerves.  The  accessory 
nuclei  have  evidently  disappeared. 

nerve.  The  nuclei  of  the  facial  are  attacked  at  a  very  early 
stage,  especially  those  which  are  connected  with  the  inferior 
branches  of  the  nerve,  and  which  I  have  named  the  accessory 
nuclei  of  the  facial.  The  annexed  diagram  {Fig.  171),  borrowed 
from  Leyden,  represents  the  morbid  changes  observed  in  the 
medulla  oblongata  in  bulbar  paralysis.  Kemnants  of  the  fun- 
damental cells  of  the  hypoglossal  nuclei  may  still  be  observed, 
while  every  trace  of  the  accessory  nuclei  has  disappeared. 

The  motor  nucleus  of  the  trigeminus  has  been  found  affected, 
but  the  nucleus  of  the  abducens  and  the  acoustic  and  trigeminal 


184  SYSTEM  DISEASES  OF   THE 

sensory  nuclei  appear  never  to  suffer.  Other  changes  have  been 
described,  but  they  appear  to  be  quite  secondary  to  the  altera- 
tions in  the  ganglion  cells.  The  pyramidal  tracts  have  often 
been  found  diseased,  and  the  degeneration  could  generally  be 
traced  into  the  pons  and  downwards  into  the  antero-lateral 
columns  of  the  cord ;  but  such  cases  are  not  pure  examples  of  the 
disease.  The  bulbar  affection  is  often  associated  with  diseases  of 
the  spinal  cord,  such  as  progressive  muscular  atrophy  and  amyo- 
trophic lateral  sclerosis.  The  roots  of  the  bulbar  nerves  are 
almost  always  atrophied,  and  degenerative  changes  have  been 
found  in  the  nerves  themselves.  The  muscles  atrophy  and 
undergo  the  same  degenerative  changes  which  are  observed  in 
progressive  muscular  atrophy.  When  the  disease  extends  into 
the  spinal  cord,  the  ganglion  cells  of  the  anterior  cornua  are 
diseased  in  the  same  manner  as  in  progressive  muscular 
atrophy.  When  the  cord  is  affected  the  spinal  nerves  issuing 
from  the  diseased  portions  and  the  muscles  to  which  they  are 
distributed  are  involved  in  morbid  action. 

§  426.  Diagnosis. — When  bulbar  paralysis  is  fully  developed, 
the  symptoms  are  so  characteristic  that  it  is  hardly  possible 
to  mistake  them,  but  the  ODset  of  the  disease  is  often  very 
insidious.  The  patient  may  complain  of  a  feeliug  of  pressure 
and  traction  in  the  back  of  the  neck,  and  a  slight  nasal 
resonance  of  the  voice,  these  being  frequently  the  first 
symptoms  to  attract  attention.  On  closer  examination  it  may 
be  observed  that  there  is  a  slight  alteration  in  the  expression 
of  the  face,  and  a  certain  degree  of  stiffness  of  the  lips,  causing 
some  imperfection  of  articulation,  and  that  the  tongue  trembles 
on  protrusion. 

In  the  fully  established  disease  the  difficulty  is  to  distinguish 
between  the  primary  and  secondary  forms  of  the  affection.  The 
diagnosis  must  be  made  from  a  careful  investigation  into  the 
history  of  the  case,  and  the  order  of  development  of  all  the 
symptoms.  The  manner  in  which  the  disease  begins  is  the 
best  guide  to  distinguish  it  from  embolism,  thrombosis,  and 
haemorrhage  in  the  medulla.  These  lesions  always  commence 
suddenly,  and  the  resulting  paralysis  is  frequently  unilateral 
or  more  pronounced  on  one  side  than  on  the  other,  while  pro- 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  185 

gressive  bulbar  paralysis  is  always  gradual  in  its  onset,  and  the 
paralysis  is  uniformly  bilateral. 

§  427.  Treatment — The  treatment  of  true  progressive  bulbar 
paralysis  has  hitherto  proved  of  little  avail,  but  much  may  be 
done  to  add  to  the  comfort  of  the  patient  and  probably  to  delay 
the  progress  of  the  disease.  Nothing  should  be  left  undone 
which  tends  to  improve  the  general  health  of  the  patient. 

The  special  remedies  which  have  been  employed  in  the 
treatment  of  the  disease  are  nitrate  of  silver,  iodide  of  potas- 
sium, iodide  of  iron,  chloride  of  gold  and  sodium,  ergotine,  and 
belladonna;  but  unless  there  is  any  special  indication  for  the 
administration  of  iodide  of  potassium  I  should,  myself,  follow 
the  advice  of  Dr.  Dowse,  and  trust  to  phosphorous,  iron,  and 
cod-liver  oil. 

The  galvanic  current  should  be  used.  Erb  advises  the 
stabile  application  of  the  current  transversely  through  the 
mastoid  processes,  and  longitudinally  through  the  skull ;  also 
galvanism  of  the  cervical  sympathetic,  by  placing  the  anode  on 
the  nucha  while  the  cathode  is  run  rapidly  over  the  lateral 
surface  of  the  larynx,  twelve  to  twenty  movements  of  degluti- 
tion being  induced  at  each  sitting.  The  galvanic  or  faradic 
current  may  be  applied  to  the  tongue,  lips,  and  palate. 

As  the  power  of  deglutition  becomes  more  and  more  impaired, 
the  food  must  be  carefully  selected  and  finely  divided,  and 
finally  the  patient  must  be  fed  through  a  tube.  Care  should  be 
taken  to  wash  the  mouth  after  eating,  and  to  remove  particles 
of  food  which  lodge  about  the  pharynx  and  underneath  the 
tongue. 

5.   Pseudo- Hypertrophic  Paralysis. 

(Atrophia  Musculerum  Lipomatosa.) 

§  428.  Definition. — This  disease  is  characterised  by  feebleness 
of  the  muscles  of  the  lower  limbs  and  of  the  erector  muscles  of 
the  spine,  gradually  extending  to  those  of  the  upper  extremities. 
The  paralysis  is  accompanied  by  atrophy  of  some  of  the  muscles, 
and  by  an  apparent  increase  in  the  volume  of  others. 

§  429.  History. — Isolated  cases  of  this  disease  were  described  many  years 
ago  by  several  authors,     A  case  was  reported  by  Sir  Charles  Bell  in  1830, 


186  SYSTEM  DISEASES   OF   THE 

one  by  Coste  and  Gioja  in  1838,  and  a  well  marked  case  by  Mr.  Partridge 
in  1847.  But  Dr.  Meryon,  in  1852,  was  the  first  to  draw  attention  to  the 
clinical  features  of  this  affection,  and  Oppenheim,  in  1855,  described  a  well 
marked  group  of  cases.  The  disease  was  thoroughly  investigated  by 
Duchenne,  His  friend,  M.  Bouvier,  sent  to  his  clinique  in  1858  a  child, 
who  had  been  suffering  from  an  unusual  form  of  paralysis,  and  during 
the  subsequent  three  years  Duchenne  collected  other  cases,  which  were 
similar  to  the  one  sent  by  Bouvier,  and  yet  did  not  correspond  to  the 
description  of  any  known  disease.  Duchenne  described  the  principal 
clinical  characters  of  the  disease  in  the  second  edition  of  his  work  on 
Localised  Electricity  (Paris,  1861),  but  it  was  not  until  1868  that  he 
published  in  the  "Archives  Gdn^rales  de  Mddecine"  a  full  account  of  his 
investigations  into  the  nature  of  the  affection.  He  then  gave  detailed 
descriptions  of  thirteen  cases,  which  had  come  under  his  own  observation, 
and  incorporated  with  these  fifteen  cases  published  up  to  that  date  by 
other  observers.  So  thoroughly  was  the  work  done  by  this  distinguished 
physician  that  nothing  essential  has  since  been  added  to  our  knowledge 
of  the  course  and  progress  of  the  disease.  Cases  have  been  described  in 
this  country  by  Mr.  William  Adams,  Dr.  Langdon  Down,  Dr.  Ord,  Mr. 
Kesteven,  Drs.  Eussell  and  Balthazar  Foster  (Birmingham),  Dr.  Barlow 
(Manchester),  Dr.  Davidson  (Liverpool),  Dr.  Clifford  Allbutt,  while  Dr. 
Gowers  has  written  an  able  monograph  on  the  disease. 

§  430.  Etiology. — This  affection  is  almost  but  not  exclusively 
confined  to  infancy.  The  first  symptoms  are  frequently  noticed 
at  the  time  when  the  child  ought  to  begin  to  walk,  although  it 
is  very  probable  that  the  disease  is  established  before  that  time. 
The  disease  begins  in  a  considerable  proportion  of  cases  between 
the  ages  of  five  and  thirteen  years,  and  cases  are  recorded  where 
adults  have  been  attacked.  It  may,  however,  be  doubted 
whether  many  of  the  latter  are  genuine  examples  of  the  disease. 
In  the  case  described  by  Auerbach,  for  instance,  the  hyper- 
trophy was  first  noticed  in  the  right  arm,  and  microscopical 
examination  of  the  affected  muscles  showed  that  the  disease 
was  more  like  true  hypertrophy.  In  the  case  described  by 
Eulenburg,  where  the  patient,  a  female,  was  forty-four  years  of 
age  when  the  first  symptoms  appeared,  the  paralysis  began  in 
the  right  arm,  in  the  form  of  progressive  muscular  atrophy, 
and  although  there  was  apparent  hypertrophy  of  the  muscles 
of  the  lower  extremities,  the  course  and  progress  of  the  case 
was  different  from  those  of  a  case  of  true  pseudo-hypertrophic 
paralysis.     In  an  undoubted  instance  of  the  disease  under  my 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  187 

care  at  present  the  patient  is  forty-seven  years  of  age,  but  the 
affection  began  at  the  age  of  ten.  It  is  much  more  common 
in  boys  than  girls.  Of  the  thirteen  cases  collected  by  Duchenne 
only  two  were  girls,  of  forty-one  cases  collected  by  Webber  only 
five  were  females,  and  of  twenty-three  cases  mentioned  by  Dr. 
Gowers  only  five  were  females.  Out  of  a  total  of  220  cases 
hitherto  published  190  were  males  and  thirty  females  (Gowers). 
The  disease  also  appears  to  pursue  a  more  chronic  course  in 
girls  than  in  boys. 

Hereditary  predisposition  to  the  disease  frequently  exists. 
Two  children  in  the  same  family  are  often  attacked,  as  in  the 
cases  related  by  Wernich,  Heller,  and  Kesteven,  and  sometimes 
even  eight  children  of  the  same  family  have  been  affected,  as  in 
the  cases  related  by  Meryon.  Lutz  met  with  two  sisters,  a 
maternal  uncle  and  aunt,  and  a  maternal  half-sister,  issue  of  a 
first  marriage,  affected  with  the  disease.  In  another  example, 
three  maternal  uncles  and  aunts  were  affected ;  in  a  second,  a 
maternal  uncle  and  a  half-uncle ;  in  a  third,  three  maternal 
half-brothers;  and  in  a  fourth  instance,  a  maternal  half-brother, 
three  maternal  uncles,  and  other  members  on  the  mother's  side 
(Poore).  It  is  curious  to  notice  that,  although  the  disease  is 
mainly  confined  to  the  male  sex,  yet  the  descent,  so  far  as  is 
known,  is  always  through  the  mother's  side.  This  disease  is 
not,  as  a  rule,  transmitted  directly  from  parents  to  offspring; 
since  by  far  the  greater  number  of  its  victims  are  attacked  at 
an  early  age,  and  therefore  do  not  become  parents,  and  this 
consideration  also  precludes  the  idea  that  it  is  an  example  of 
atavism.  A  certain  predisposition  is,  therefore,  transmitted, 
which,  with  the  concurrence  of  other  unfavourable  circumstances, 
such  as  an  eruptive  fever,  develops  the  disease. 

The  exciting  causes  of  the  disease  are  by  no  means  clear. 
Exposure  to  cold  and  damp  appears  to  be  occasionally  the 
determining  cause,  while  at  other  times  it  has  followed  an 
eruptive  fever,  variola,  or  measles,  and  several  cases  have  been 
ushered  in  by  convulsions. 

§  431.  Symptoms. — Feebleness  of  the  lower  extremities  is 
usually  the  first  symptom  to  attract  attention,  and  when  the 
disease  begins  during  infancy  it  is  difficult  to  fix  the  exact  date 


188  SYSTEM  DISEASES   OF   THE 

of  its  origin.  The  attention  of  the  parents  is  not  directed  to  the 
condition  of  the  child  until  he  arrive  at  the  age  when  other 
children  begin  to  walk.  At  this  period  it  is  noticed  that  when  the 
child  is  placed  on  his  feet  he  does  not  instinctively  move  his 
legs  to  walk,  but  immediately  falls  down,  and  in  other  cases 
he  may  have  begun  to  walk,  but  is  soon  fatigued  and  can 
no  longer  stand  steadily  or  walk  without  stumbling.  At 
other  times  the  child  may  be  late  in  attempting  to  walk, 
and  is  obliged  to  support  himself  by  holding  on  to  the 
nearest  article  of  furniture.  The  parents  are  not  readily 
alarmed  at  the  inability  of  the  child  to  walk,  inasmuch 
as  the  limbs  appear  to  be  so  well  developed.  When 
standing  or  walking  the  feet  are  widely  separated  from  one 
another,  and  when  they  are  made  to  approach  each  other 
walking  is  rendered  difficult,  and  the  child  may  fall.  In 
walking,  the  body  is  inclined  from  side  to  side,  so  that  the 
gait  resembles  the  waddling  of  a  duck.  When  the  feet  are 
kept  widely  apart  the  centre  of  gravity  at  each  step  must  be 
carried  well  over  to  the  side  of  the  active  leg,  in  order  that 
the  line  of  gravity  may  pass  through  the  centre  of  the  arch 
of  the  foot  planted  on  the  ground.  Duchenne  thought  that  the 
oscillation  of  the  body  in  walking  depended  upon  weakness  of 

the  gluteus  medius.   But  in  the  case  of  Charlotte  A ,  already 

described  (§  412),  the  gluteus  medius  on  both  sides  was 
paralysed,  yet  instead  of  the  waddling  gait  so  characteristic  of 
pseudo-hypertrophic  paralysis,  the  head  and  body  were  moved 
forwards  during  locomotion  in  a  straight  line  without  the 
normal  lateral  inclination  of  them  being  observed. 

In  several  cases  of  pseudo-hypertrophic  paralysis  which  I 
have  examined  with  reference  to  this  point,  on  placing  one  of 
my  hands  on  each  side  of  the  pelvis  immediately  above  the 
trochanters,  the  gluteus  medius  on  the  side  of  the  active  leg 
could  be  distinctly  felt  to  contract  at  each  successive  step. 
The  patients  also,  when  lying  on  one  side,  with  legs  extended, 
are  able  to  raise  the  upper  leg  away  from  the  other,  without 
much  apparent  difficulty,  and  when  the  hand  is  placed  over 
the  gluteus  medius  during  this  movement  the  muscle  may 
be  felt  to  contract  powerfully.  In  an  advanced  case  of  the 
disease  which  I  saw  recently  along  with  my  friend  Dr.  John 


SPINAL   COED  AND   MEDULLA   OBLONGATA.  189 

Brown,  of  Burnley,  the  patient  could  not  stand  or  sit  erect,  yet 
when  lying  on  his  side  he  could  abduct  the  upper  leg,  and  on 
placing  my  hand  above  the  great  trochanter  of  the  femur  the 
gluteus  medius  was  felt  to  contract.  This  muscle  was,  therefore, 
not  likely  to  have  been  affected  at  an  early  period  of  the  affec- 
tion. The  oscillation  of  the  body  in  walking,  therefore,  instead 
of  being  caused  by  paralysis  of  the  gluteus  medius,  is,  in  my 
opinion,  mainly  effected  by  contraction  of  this  muscle.  The 
lateral  inclination  of  the  body  appears,  indeed,  to  be  rendered 
necessary  in  the  early  stage  of  the  affection  partly  by  the  legs 
being  held  widely  apart,  and  partly  by  the  inability  of  the 
patient  to  produce  dorsal  flexion  of  the  foot  so  as  to  allow  the 
passive  leg  to  swing  forward  in  locomotion. 

In  the  second  stage  of  the  disease,  when  double  talipes 
equinus  and  dorsal  curvature  are  established,  other  factors  co- 
operate in  the  production  of  the  alternate  balancings  of  the 
body.  When  talipes  equinus  is  once  formed,  the  body  at  each 
successive  step  must  be  delicately  balanced  so  that  the  line  of 
gravity  will  pass  through  the  ball  of  the  foot,  and  consequently 
the  slightest  displacement  of  the  centre  of  gravity  would  cause 
the  patient  to  fall.  It  is  therefore  necessary  that  at  each  step 
the  body  should  be  inclined  well  over  to  the  side  of  the  active 
leg,  and  the  patient  aids  himself  in  balancing  the  body  on  the 
ball  of  the  foot  on  the  side  of  the  active  leg  by  moving  his 
arms  about  like  a  rope  dancer. 

When  the  patient  is  laid  down  or  falls,  he  raises  himself  in  a 
characteristic  manner.  If  any  object  be  near  which  he  can 
conveniently  grasp,  such  as  a  chair  or  other  article  of  furniture, 
he  drags  himself  up  by  his  arms.  When  the  patient  has  to  get 
up  without  extraneous  aid,  he  first  raises  himself  on  his  hands 
and  feet.  In  the  first  position  which  he  assumes  the  patient's 
feet  are  planted  on  the  ground,  the  different  segments  of  the 
lower  extremities  are  slightly  flexed  upon  one  another,  the 
body  is  flexed  on  the  lower  extremities,  and  the  head  directed 
downwards,  and  the  tips  of  the  fingers  of  both  hands  rest  on  the 
ground  a  little  in  front  of  the  toes  (Plate  III.,  1).  The  patient 
next  raises  his  hand,  say  the  left,  and  places  it  above 
the  left  knee.  The  body  is  now  drawn  over  to  the  opposite 
side  so  that  its  weight  rests  mainly  on  the  right  leg,  by  one 


190  SYSTEM  DISEASES  OF  THE 

vigorous  push  of  the  left  arm  the  left  knee-joint  is  thrust  back- 
wards, and  the  leg  and  thigh  are  thus  extended  one  upon 
anotlier,  while  the  body  is  at  the  same  time  thrust  upwards. 
The  feeble  extensors  of  the  body  on  the  thigh  are  now  brought 
into  action,  and  the  trunk  is  partly  raised  upwards  by  their 
contraction,  and  partly  pushed  upwards  by  the  left  upper 
extremity,  while  the  right  may  not  require  to  be  placed  over 
the  right  knee  in  the  early  stage  of  the  affection. 

But  even  in  the  early  stage  of  the  disease  the  action  of  the 
extensors  of  the  body  on  the  thighs  is  greatly  aided  by  the  abduc- 
tors of  the  thighs,  and  the  patient  may  be  observed  to  elevate  the 
trunk  by  a  kind  of  rotatory  movement,  the  body  being  drawn 
first  to  the  one  side  and  then  to  the  other. 

The  following  case  has  afforded  me  an  opportunity  of  studying 
the  different  movements  which  are  made  in  the  act  of  attaining 
the  erect  posture,  inasmuch  as  these  are  slowly  performed;  and 
as  the  case  is  of  interest  in  other  respects,  I  shall  describe  the 
symptoms  in  detail.  I  have  received  valuable  assistance  from 
Dr.  A.  H.  Young  in  describing  the  different  groups  of  muscles 
which  are  brought  into  action  by  the  patient  in  attaining  the 
erect  posture. 

Peter  P ,  forty-five  years  of  age,  was  admitted  to  the  Eoyal  Infirmary, 

Manchester,  February  12th,  1880.  He  was  quite  healthy  until  ten 
years  of  age,  when  he  had  an  attack  of  typhoid  fever.  During  the  attack 
of  fever  he  suffered  from  bed-sores,  and  his  recovery  was  slow  and  pro- 
tracted. Subsequent  to  this  period  he  could  ascend  a  stair  without 
difficulty,  and  could  carry  weights  like  other  people.  He  thinks,  however, 
that  his  mode  of  walking  was  peculiar,  and  that  he  was  weak  on  his  legs. 
He  could  not  join  in  games  which  required  active  exercise,  as  running,  and 
the  other  boys  at  school  amused  themselves  by  pushing  against  him  and 
throwing  him  down.  At  fifteen  years  of  age  he  was  apprenticed  to  a  joiner, 
and  was  then  able  to  ascend  a  ladder  and  perform  the  ordinary  work.  It 
was  not,  indeed,  until  he  was  thirty  years  of  age  that  his  present  symptoms 
began  to  attract  attention.  At  this  time  his  master  observed  that  he  was 
unable  to  get  through  his  work  like  the  other  men,  and  consequently  he 
was  the  first  to  be  discharged  when  work  was  scarce.  The  first  symptom 
which  attracted  his  attention  was  that  he  was  unable  to  ascend  a  stair 
without  placing  his  hand  on  his  knee,  while  holding  on  to  the  banister  with 
the  other  hand.  From  that  time  up  to  the  present,  a  period  of  thirteen 
years,  he  has  become  gradually  and  slowly  worse.  He  was  married  thir- 
teen years  ago,  and  has  three  children,  all  of  whom  are  healthy. 

Present  Condition.—  The  patient  seems  fairly  well  nourished  and  healthy. 


SPINAL   CORD   AKD   MEDULLA   OBLONGATA.  191 

There  is  a  cicatrix  two  inches  in  diameter  on  the  prominent  part  of  the 
sacrum,  and  a  smaller  one  over  the  great  trochanter  of  the  femur,  on  each 
side,  these  being  left  by  the  bed-sores  from  which  he  suffered  when  ill  of 
typhoid  fever. 

As  the  patient  stands  on  the  floor  in  the  erect  posture  his  feet  are 
4^  inches  apart  at  the  heels  and  10  inches  at  the  toes.  The  heels  scarcely 
touch  the  ground  ;  when  he  stands  on  his  naked  feet  a  piece  of  cardboard 
can  be  readily  passed  between  the  heels  and  the  floor.  When  he  raises  his 
foot  off  the  ground  it  assumes  the  position  of  talipes  equino-varus,  and  he 
cannot  produce  dorsal  flexion  of  the  foot,  but  there  is  no  deformity  of  the 
toes.  When  the  patient  is  standing  the  muscles  of  the  calf  are  hard,  tense, 
comparatively  large,  and  well  formed.  The  muscles  of  the  thigh  are  small, 
soft,  and  flabby,  so  that  the  comparatively  slender  thighs  offer  a  striking 
contrast  to  the  large  and  well  formed  calves.  The  buttocks  are  somewhat 
flattened,  and  fibrillary  movements  are  observed  in  the  erector  spinse  and 
the  muscles  of  the  back  of  the  thigh.  The  scapular  muscles  are  unaffected, 
the  deltoids  are  prominent,  and  act  with  great  energy  on  voluntary  effort. 
The  pectoral  muscles  are  decidedly  atrophied,  and  the  triceps,  biceps,  and 
the  coraco-brachialis  are  wasted  to  so  marked  a  degree  that  the  slenderness 
of  the  arm  offers  a  strong  contrast  to  the  full  and  rounded  shoulder  caused 
by  the  prominence  of  the  deltoid.  The  muscles  of  the  forearm  are  not 
atrophied,  and  they  stand  out  prominently  under  the  skin,  and  feel  hard 
and  tense  when  the  patient  grasps  anything  strongly,  yet  his  grasp  is 
remarkably  feeble.  Dr.  Leech,  who  has  made  a  microscopic  examination 
of  portions  of  these  muscles  withdrawn  by  his  trocar,  assures  me  that 
they  exhibit  morbid  changes,  but  he  is  unable  to  say  that  they  are  the  same 
as  those  which  characterise  pseudo-hypertrophy  of  muscle. 

The  following  measurements  were  taken :  Height  5ft.  7in.,  circumference 
of  the  chest  32in.,  abdomen  Sl^in.,  upper  part  of  each  thigh  16|in.,  middle 
of  each  thigh  13in.,  each  calf  13|in.,  upper  arm  7jin.,  forearm  9jin.  The 
circumference  of  the  calf  exceeds  that  of  the  middle  of  the  thigh,  while 
the  circumference  of  the  forearm  greatly  exceeds  that  of  the  upper  arm. 
While  standing  the  pelvis  is  inclined  well  forwards,  his  abdomen  is  some- 
what protuberant ;  while  the  upper  part  of  his  body  is  dragged  backwards, 
so  that  a  deep  curve,  with  its  concavity  directed  backwards,  is  formed  in 
the  lumbo-dorsal  region.  A  plumb-line,  let  fall  from  the  most  prominent 
of  the  spinous  processes  of  the  upper  dorsal  vertebrse,  falls  three  inches 
behind  the  sacrum. 

Walking. — The  gait  of  the  patient  is  peculiar  and  characteristic ;  the 
body  is  alternately  drawn  from  side  to  side,  giving  to  the  walk  a  duck-like 
or  waddling  movement.  The  patient,  as  already  remarked,  can  neither 
place  the  two  heels  firmly  on  the  ground  at  the  same  time,  nor  elevate  the 
toes  by  producing  dorsal  flexion  of  the  foot,  and  consequently  the  passive 
leg  cannot  swing  forwards  with  the  normal  pendulum  movement. 

The  difficulty  of  moving  the  passive  leg  forwards  is,  indeed,  increased 
by  the  fact  that  the  predominant  action  of  the  muscles  of  the  calf  extends 


192  SYSTEM   DISEASES  OF  THE 

the  foot  on  the  leg  when  once  it  is  raised  off  the  ground,  so  that  the  limb 
is  lengthened  instead  of  being  shortened  by  dorsal  flexion  of  the  foot,  as 
in  normal  locomotion.  Under  these  circumstances  the  toes  of  the  passive 
leg  are  made  to  clear  the  ground  by  a  different  mechanism  from  that 
which  obtains  in  health.  The  feet  are,  as  already  described,  held  widely 
apart ;  and  when  the  passive  leg,  say  the  right,  is  to  be  moved  forwards 
the  body  is  dragged  well  over  to  the  left.  This  movement  is  mainly 
effected  by  the  abductors  of  the  thigh  on  the  side  of  the  active  leg,  and 
the  gluteus  medius  on  that  side  is  felt  strongly  contracted  on  placing  the 
hand  over  it.  But  the  centre  of  gravity  is  not  only  drawn  over  to  the 
side  of  the  active  leg,  but  it  is  also  drawn  somewhat  backwards  by  the 
action  of  the  gluteal  and  probably  also  the  hamstring  muscles,  and  the  line 
of  gravity  in  passing  through  the  arch  of  the  left  foot  approaches  the  heel, 
and  the  latter  is  now  felt  to  be  firmly  planted  on  the  ground.  During 
this  double  but  combined  movement  the  line  of  gravity  is  in  danger  of 
being  carried  too  far  to  the  left  and  backwards,  hence  the  right  arm  is 
thrown  outwards  and  forwards  so  as  to  maintain  the  centre  of  gravity  as 
far  to  the  right  and  forwards  as  possible.  During  the  lateral  movement 
of  the  body  towards  the  side  of  the  active  leg  the  pelvis  on  the  side  of  the 
passive  leg  is  elevated,  and  thus  the  length  between  the  head  of  the  femur 
and  ground  is  increased,  and  during  the  backward  movement  of  the  body 
the  pelvis  is  made  to  assume  a  more  vertical  position,  so  that  the  flexors  of 
the  thigh  on  the  body  can  act  more  efiiciently  on  the  passive  leg.  The 
thigh  of  the  passive  leg  is  now  flexed  on  the  body,  the  abductors  also 
contracting  and  giving  to  the  thigh  an  outward  inclination,  the  leg  is 
slightly  flexed  on  the  thigh,  and  the  foot  is  moved  slowly  forwards  and 
outwards,  and  when  the  step  is  completed  the  toe  comes  first  to  the 
ground. 

The  forward  and  outward  projection  of  the  passive  leg  tends  to  counter- 
act the  tendency  of  the  line  of  gravity  to  pass  too  far  to  the  side  of  the 
active  leg  and  backwards.  When  the  passive  leg  is  placed  on  the  ground 
the  abductors  of  the  thigh  on  that  side  contract,  the  body  is  drawn  over 
to  the  right,  and  the  line  of  gravity  is  slowly  transferred  to  the  leg  that 
was  passive  and  which  now  in  its  turn  becomes  active. 

Attaining  the  Erect  Posture. — On  rising  from  the  recumbent  position 
the  patient  first  gets  on  his  hands  and  knees,  and  placing  his  right  foot  on 
Ihe  ground,  he  rests  his  right  elbow  above  the  knee,  and  inclines  his  trunk 
to  the  right  so  that  the  centre  of  gravity  passes  through  the  right  foot. 
When  he  leans  well  forwards  in  this  position  and  presses  his  right  elbow 
downwards  and  backwards,  it  will  tend  to  drag  the  trunk  and  with  it  the 
right  hip-joint  forwards,  but  inasmuch  as  the  right  knee  is  at  the  same 
time  pressed  downwards  and  backwards,  any  forward  movement  of  the 
hip-joint  must  be  accompanied  by  elevation.  The  weight  of  the  trunk  is, 
therefore,  so  applied  that  it  tends  to  drag  the  hip-joint  forwards  and 
upwards,  and  thus  to  extend  the  trunk  on  the  thighs  and  to  push  the  right 
knee-joint  downwards  and  backwards,  and  thus  to  extend  the  leg  upon 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  193 

the  thigh,  so  that  the  weight  of  the  trunk  is  so  appUed  as  to  aid  the 
extensors  in  erecting  the  body. 

The  extensor  muscles  are  now  brought  into  action,  and  the  trunk  is 
slowly  elevated  to  what  I  may  call  the  second  position.  In  this  position 
the  various  segments  of  the  right  lower  extremity  are  slightly  flexed  upon 
one  another,  the  trunk  is  directed  forwards  horizontally,  and  the  right 
elbow  rests  above  the  knee,  while  the  left  thigh  is  directed  vertically 
downwards,  the  left  leg  is  inclined  downwards  and  backwards,  and  the  toe 
rests  on  the  ground  considerably  behind  the  right  foot,  while  the  left  hand 
rests  lightly  on  the  left  thigh  immediately  above  the  knee. 

After  a  momentary  pause  the  patient  proceeds  to  attain  the  third  posi- 
tion. The  abductors  of  the  right  thigh  contract  and  rotate  the  pelvis  so 
that  the  left  hip-joint  is  slightly  elevated.  This  movement  brings  the  line 
of  gravity  well  within  the  right  foot,  and  takes  the  weight  of  the  trunk 
entirely  off  the  left  lower  extremity.  The  left  foot  is  now  drawn  forwards 
and  placed  on  the  ground  in  a  line  with  the  right  foot,  but  slightly  removed 
from  it  laterally,  while  the  left  hand  at  the  same  time  grasps  the  left  thigh 
immediately  above  the  knee.  By  a  contraction  of  the  abductors  and  ex- 
tensors of  the  left  thigh  the  line  of  gravity  is  now  transferred  from  the 
right  to  the  left  foot,  the  right  shoulder  is  elevated,  and  the  right  hand 
is  quickly  transferred  to  the  position  previously  occupied  by  the  elbow  ; 
the  abductors  and  extensors  of  the  left  thigh  now  relax,  until  the  line  of 
gravity  passes  between  the  feet,  and  the  third  position  is  attained. 

In  this  position  the  two  sides  are  symmetrically  placed.  The  feet  are 
placed  on  the  ground  and  somewhat  removed  from  one  another,  but  the 
heels  do  not  quite  touch  the  ground ;  the  legs  are  slightly  fl,exed  on  the 
feet,  the  thighs  on  the  legs,  and  the  trunk  on  the  thighs ;  both  arms  pass 
downwards  and  backwards,  each  hand  grasping  the  thigh  of  the  corre- 
sponding side  close  above  the  knee.  When  the  patient  is  viewed  laterally, 
the  thigh,  arm,  and  trunk  are  seen  to  form  the  three  sides  of  a  triangle 
(Plate  III.,  3),  and  the  weight  of  the  trunk  applied  through  the  arms 
must  tend  to  push  both  knees  downwards  and  backwards,  while  at  the 
same  time  tending  to  elevate  the  hip-joints.  The  body  is  inclined 
forwards  and  upwards,  but  owing  to  the  deep  dorso-lumbar  curve  the 
vertical  axis  of  the  pelvis  occupies  a  more  horizontal  position  than  might 
be  expected  from  the  upward  inclination  of  the  body.  The  line  which 
joins  the  anterior  superior  spine  of  the  ilium  and  the  head  of  the 
femur  forms  nearly  a  right  angle  with  that  which  joins  the  head  of 
the  femur  and  the  centre  of  the  arch  of  the  foot ;  and,  consequently,  were 
the  gluteus  medius  and  minimus  of  both  sides  now  to  contract,  they  would 
act  mainly  as  flexors  of  the  pelvis  on  the  thighs. 

The  patient,  after  a  little  pause  to  take  breath,  prepares  for  a  further 
elevation  of  the  body,  the  great  difficulty  he  has  to  encounter  is  to  erect 
the  pelvis  on  the  thighs,  while  at  the  same  time  extending  the  various 
segments  of  the  lower  extremities  upon  one  another.  By  transferring  the 
line  of  gravity  from  one  foot  to  the  other  he  takes  the  weight  of  the  body 
N 


194  SYSTEM  DISEASES   OF  THE 

off  each  foot  alternately,  and  in  this  way  he  is  enabled  to  slip  by  turns 
each  hand  further  up  the  thighs  until  he  grasps  them  about  the  junction 
of  the  middle  with  the  lower  third.  The  trunk  is  now  dragged  over  to  the 
left,  so  that  the  line  of  gravity  passes  through  the  left  foot,  and  the  right 
hand  is  removed  from  the  right  thigh  (Plate  III.,  4).  The  right  foot  is 
shuffled  outwards  and  backwards,  so  as  to  allow  the  leg  to  be  fully  extended 
on  the  thigh.  This  movement  is  performed  with  great  deliberation,  and 
after  it  is  effected  the  patient  rests  for  a  moment  as  if  to  assure  himself 
that  the  right  foot,  which  now  rests  on  its  inner  edge  considerably  behind 
and  removed  from  the  left  foot,  is  firmly  planted  so  as  not  to  slip.  The 
final  effort  now  begins.  Apparently  by  a  combined  action  of  the  inward 
rotators  of  the  left  and  of  the  outward  rotators  of  the  right  thigh  the 
pelvis  is  rotated  obliquely  from  before  backwards  and  from  right  to  left. 
By  this  movement  the  right  hip-joint  is  brought  well  forwards,  and  the 
pelvis  is  probably  also,  by  a  simultaneous  action  of  the  extensors  of  the 
body  on  the  thigh,  made  to  assume  a  more  vertical  position.  But  what- 
ever may  be  the  nature  of  the  muscular  action  concerned  in  this  move- 
ment, when  it  is  completed  the  head  of  the  right  femur  is  placed  almost 
vertically  below  the  anterior  superior  spine  of  the  ilium,  instead  of  being 
on  the  same  horizontal  plane  with  it  as  in  the  third  position.  The  line 
which  joins  the  anterior  superior  spine  of  the  ilium  and  the  great  tro- 
chanter now  forms  a  very  obtuse  angle  with  that  joining  the  great 
trochanter  and  the  middle  of  the  arch  of  the  foot,  and  in  this  position  the 
gluteus  minimus  and  medius  will  act  mainly  as  extensors  of  the  pelvis  on 
the  thighs.  The  great  effort  of  the  patient  is  now  directed  to  transfer  the 
line  of  gravity  from  the  left  to  the  right  foot.  This  is  effected  by  the 
trunk  being  dragged  over  in  a  diagonal  manner  from  before  backwards 
and  from  left  to  right,  partly  by  the  conjoined  action  of  the  extensors  and 
abductors  of  the  right  thigh,  and  partly  by  the  left  shoulder  being  pushed 
upwards  and  to  the  opposite  side  by  forces  acting  upon  it  from  below 
through  the  arm.  The  elevation  of  the  left  shoulder  is  effected  by  the 
extension  of  the  different  segments  of  the  arm  upon  one  another,  and  by 
the  elevation  of  the  heel  and  consequently  of  the  knee  by  contraction  of 
the  muscles  of  the  calf.  The  upward  movement  of  the  left  shoulder  is 
not  one  of  simple  elevation,  but  is  indeed  a  very  complex  act.  The  left 
knee  is  not  only  elevated  by  contraction  of  the  muscles  of  the  calf,  but  a 
strong  contraction  of  the  adductors  of  the  thigh  prevents  it  from  being 
thrust  out  laterally.  The  inward  rotators  of  the  left  arm  (the  latissimus 
dorsi,  teres  major  and  minor,  and  infraspinatus),  and  the  abductors  of  the 
arm,  especially  the  posterior  third  of  the  deltoid,  enter  into  strong  con- 
traction. The  tendency  of  the  combined  action  of  these  muscles  is,  the 
arm  being  fixed  by  the  hand  grasping  the  knee,  to  thrust  the  left  shoulder 
to  the  opposite  side,  and  to  rotate  the  body,  so  that  the  left  shoulder  is 
pushed  forwards  in  advance  of  the  right  one.  We  have  already  seen  that 
the  pelvis  was  rotated  in  such  a  way  that  the  right  was  placed  in  advance 
of  the  left  hip-joint,  and  now  the  left  is  pushed  forwards  in  advance  of 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  195 

the  right  shoulder,  and  consequently  the  upper  part  of  the  body  is  being 
rotated  in  the  opposite  direction  to  the  lower  part ;  or,  in  other  words,  the 
pelvis  is  being  rotated  from  right  to  left  through  the  hip-joints,  and  from 
left  to  right  through  the  vertebral  column,  the  power  in  the  latter  case 
being  applied  on  a  level  with  the  brim  of  the  pelvis.  If  the  forces  which 
tend  to  rotate  the  pelvis  from  right  to  left,  and  those  which  tend  to  rotate 
it  from  left  to  right  were  applied  on  the  same  level,  they  would  tend  to 
neutralise  one  another,  and  the  pelvis  would  remain  more  or  less  fixed. 
But,  inasmuch  as  the  forces  which  rotate  the  pelvis  from  right  to  left 
are  applied  through  the  hip-joints,  and  those  which  tend  to  rotate  it  from 
left  to  right  through  the  vertebral  column,  the  consequence  is  that  the 
former  will  tend  to  push  the  head  of  the  right  femur  forwards,  while  the 
latter  will  tend  to  carry  the  brim  of  the  right  ilium  backwards.  It  will 
be  thus  seen  that  the  forward  rotation  of  the  left  shoulder  will  tend  to 
carry  the  anterior  superior  spine  of  the  right  ilium  backwards,  and  there- 
fore assists  the  action  of  the  gluteus  medius  and  minimus  of  the  right  side 
as  extensors  of  the  body  on  the  thigh.  It  may,  indeed,  be  said  that  the 
double  rotation  just  described  twists  or  screws  the  pelvis  into  a  more  or 
less  erect  position  with  reference  to  the  right  lower  extremity,  around  the 
hip-joint  of  which  all  the  movements  of  the  body  at  present  centre. 

As  the  line  of  gravity  approaches  the  right  foot,  the  left  lower  extremity 
is  becoming  more  and  more  inclined  forwards  and  outwards,  its  different 
segments  become  extended  upon  one  another,  and  the  toe  rests  on  the 
ground.  When  once  the  line  of  gravity  passes  through  the  right  foot,  the 
extensors  and  abductors  of  the  right  thigh  relax  somewhat,  while  those  of 
the  left  now  suddenly  contract ;  the  pelvis  is  rotated  once  more  in  such  a 
way  that  the  head  of  the  left  femur  is  brought  forwards  under  the  pelvis. 
During  this  movement  the  left  hand  is  removed  from  the  thigh,  the 
muscles  of  the  calf  relax,  the  heel  comes  to  the  ground,  and  the  line  of 
gravity  is  for  a  moment  transferred  to  the  left  foot,  but  immediately  after- 
wards the  weight  of  the  body  is  borne  by  both  feet,  the  line  of  gravity 
falling  between  them,  and  the  erect  posture  is  attained. 

When  the  patient  reclines  on  one  side  he  can  raise  the  uppermost  leg 
away  from  the  other  with  a  considerable  degree  of  force,  and  during  this 
action  the  gluteus  medius  can  be  felt  strongly  contracted. 

When  sitting  he  can  cross  one  leg  over  the  other  readily,  abduct  and 
adduct  his  legs  with  considerable  force  against  a  resisting  object,  but  he 
can  only  produce  dorsal  flexion  of  the  foot  to  a  slight  extent. 

Owing  to  the  feebleness  of  the  gluteus  maximus,  the  patient 
experiences  great  difficulty  in  getting  up  steps,  and  the  manner 
in  which  he  ascends  a  stair  is  as  characteristic  as  that  in  which 
he  attains  the  erect  posture.  He  lays  hold  of  the  railing  with 
one  hand,  say  the  right,  and  by  the  contraction  of  the  muscles 
of  the  right  upper  extremity  he  drags  his  body  upwards  at  each 


196  SYSTEM  DISEASES   OF   THE 

step.  The  right  arm  is,  however,  assisted  by  the  left.  The  Jeft 
hand  is  planted  above  the  left  knee,  and  each  time  the  left  leg 
is  raised  a  step  the  body  is  thrust  upwards  by  the  various 
segments  of  the  left  arm  being  extended  upon  one  another. 

One  of  the  most  constant  symptoms  of  the  disease  is  the 
existence,  during  standing  or  walking,  of  a  remarkable  curva- 
ture of  the  spine  in  the  lumbo-sacral  region.  The  shoulders 
and  upper  part  of  the  vertebral  column  are  carried  backwards, 
so  that  a  plumb-line  let  fall  from  the  most  prominent  spinous 
process  of  the  vertebrae  falls  behind  the  sacrum.  I  have,  how- 
ever, observed  an  undoubted  example  of  the  disease  in  which 
the  plumb-line  did  not  clear  the  sacrum.  Duchenne  attributes 
this  incurvation  to  weakness  of  the  erector  muscles  of  the  spine; 
but,  as  pointed  out  by  Dr.  Gowers,  weakness  of  the  extensors  of 
the  pelvis  on  the  thighs  contributes  to  the  formation  of  the 
lordosis.  Weakness  of  the  extensors  allows  the  pelvis,  and 
with  it  the  lowest  lumbar  vertebrae,  to  incline  forwards  in  the 
erect  posture,  and  a  compensatory  backward  inclination  of  the 
dorsal  spine  is  necessary  in  order  to  keep  the  centre  of  gravity 
in  the  normal  position. 

Another  important  feature  of  the  disease  is  that  the  patient 
has  a  difficulty  in  bringing  his  heels  to  the  ground  ;  and,  as  the 
case  advances,  a  permanent  condition  of  talipes  equinus,  or 
equino-varus,  is  established.  The  foot  becomes  more  hollow 
from  increase  of  the  plantar  arch,  while  paralysis  of  the  inter- 
ossei  causes  the  first  phalanges  to  be  maintained  in  a  state  of 
exaggerated  extension  on  the  metatarsal  bones,  and  the  two 
distal  phalanges  to  be  flexed,  so  that  the  toes  assume  the 
peculiar  clawlike  appearance,  which  Duchenne  has  called  griffe 
dea  orteils. 

The  apparent  hypertrophy  of  the  muscles,  which  is  the  most 
characteristic  symptom  of  the  disease,  generally  begins  by  en- 
largement of  one  calf,  the  other  also  becoming  affected  before 
very  long.  This  is  the  usual  mode  of  invasion,  but  sometimes 
the  muscular  enlargement  begins  in  the  muscles  of  the  upper 
extremities,  as  in  a  case  related  by  Duchenne,  where  the 
deltoids  had  begun  to  enlarge  many  months  before  the  gastro- 
cnemii.  The  gluteal  muscles  become  affected  soon  after  those 
of  the  calf,  and  then  the  disease  extends  in  succession  to  the 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  197 

lumbo-spinal  muscles  and  to  some  of  the  muscles  of  the  thigh, 
trunk,  and  upper  extremities.  Of  the  muscles  of  the  upper 
extremities  the  deltoids  are  usually  the  first  to  suffer.  In  one 
case  related  by  Duchenne  the  apparent  hypertrophy  had  become 
so  general  that,  with  the  exception  of  the  pectoral  muscles,  the 
latissimus  dorsi,  and  the  sterno-mastoids,  all  the  muscles  of  the 
limbs,  trunk,  and  even  those  of  the  face,  especially  the  tem- 
porals, were  successively  invaded.  In  a  case  related  by  Weir 
Mitchell  not  only  the  muscles  of  the  face,  but  even  those  of 
the  tongue,  were  hypertrophied. 

The  affected  muscles  may  attain  an  enormous  volume,  and 
stand  out  so  prominently  under  the  skin  that  Duchenne  uses 
the  term  "  hernial  protrusions  "  to  describe  their  appearance. 
The  muscles  also  feel  hard  and  resisting  to  the  touch,  so  that 
the  whole  appearance  of  the  child  often  suggests  the  idea  of 
Herculean  strength  instead  of  the  great  feebleness  which  in 
reality  exists.  But  even  amidst  all  this  apparent  development 
of  muscular  power  there  are  not  wanting  visible  indications  of 
the  real  nature  of  the  malady.  Some  of  the  muscles  are  always 
found  atrophied,  their  wasted  condition  contrasting  strongly 
with  the  excessive  size  of  the  others.  Even  in  the  case  related 
by  Duchenne,  where  the  child  looked  like  a  young  Hercules, 
the  pectorals  and  latissimus  dorsi  were  atrophied.  In  the 
majority  of  cases  the  muscles  of  the  calves  and  buttocks,  and 
probably  also  the  deltoids,  are  enlarged,  while  the  remaining 
muscles  of  the  arm,  forearm,  shoulders,  and  trunk  are  atrophied; 
so  that  the  slenderness  of  the  upper  part  of  the  body  offers  a 
strong  contrast  to  the  abnormal  development  of  the  inferior 
extremities.  We  see,  therefore,  that  all  the  paralysed  muscles 
do  not  undergo  augmentation  of  bulk;  in  fact,  atrophy  of  some 
of  the  muscles  is  a  constant  symptom  of  the  disease.  Another 
circumstance  worth  noting  is  that  the  degree  of  paralysis  has 
no  direct  relation  to  the  amount  of  hypertrophy.  This  is  well 
illustrated  in  the  leg  where  the  action  of  the  extensors  of  the 
foot,  although  these  are  much  enlarged,  predominates  over  that 
of  the  flexors,  as  evinced  by  the  elevation  of  the  heel. 

The  disease  now  becomes  more  or  less  stationary  for  two  or 
three  years,  and  sometimes  for  a  much  longer  period,  and  as 
the  general   health    is  good  and   the   muscular  development 


198  SYSTEM  DISEASES   OF  THE 

apparently  very  powerful,  the  parents  cannot  believe  that  the 
affection  is  incurable.  This  illusion  is,  however,  after  a  time 
destined  to  be  dispelled.  The  feebleness  of  the  lower  extre- 
mities gradually  increases,  so  that  the  child  cannot  maintain 
the  erect  posture,  while  the  muscles  of  the  superior  extremities 
also  become  both  paralysed  and  atrophied ;  and  even  the  hyper- 
trophied  limbs  begin  to  waste,  and  to  diminish  rapidly  in  size. 
The  patient,  now  arrived  at  adolescence,  may  live  on  for  several 
years  in  a  condition  of  almost  complete  paralysis,  until  finally 
death  takes  place  from  exhaustion,  implication  of  the  respiratory 
muscles,  or  more  usually  from  some  intercurrent  affection. 

There  are  still  some  minor  features  of  the  disease  which 
deserve  attention.  The  statements  of  different  observers,  with 
respect  to  the  electro-muscular  contractility,  are  somewhat  con- 
tradictory. Except  in  the  very  early  stages  of  the  disease,  the 
faradic  contractility  is  diminished,  while  the  galvanic  contrac- 
tility may  be  normal  or  increased.  In  the  second  stage  of  the 
disease  the  quadriceps  tendon-reflex  is  completely  abolished. 

Very  frequently  the  skin  over  the  affected  parts  presents  a 
peculiar  mottled  appearance,  the  colour  varying  in  different 
cases,  and  in  the  same  case  according  to  the  degree  of  exposure. 
Sometimes  it  is  described  as  of  a  roseate  hue,  again  as  bright 
red,  and  at  other  times  as  consisting  of  patches  of  purplish 
colour  alternating  with  white.  All  of  these  phenomena,  how- 
ever, indicate  capillary  congestion,  the  result  of  vaso-motor  dis- 
turbance. This  supposition  is  still  further  strengthened  by  the 
fact  that  the  superficial  temperature  of  the  inferior  extremities 
is  frequently  higher  than  that  of  the  trunk. 

This  disease  is  often  associated  with  a  certain  amount  of 
mental  incapacity.  In  several  instances  the  subjects  of  it  have 
been  noticed  to  be  slow  in  acquiring  the  power  of  speech,  others 
are  described  as  being  obtuse  in  intelligence,  and  a  considerable 
number  have  been  idiots.  The  disease  is  not  accompanied  by 
any  suffering,  there  is  no  alteration  of  sensibility,  and  the  func- 
tions of  the  bladder  and  rectum  are  not  interfered  with,  while 
the  general  health  is  not  much  affected  until  near  the  terminal 
period  of  the  affection, 

§  432,    Course  and  Duration. — The  disease  is  essentially 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  199 

chronic.  It  begins  without  fever  or  marked  derangement  of 
the  functions  of  digestion,  respiration,  or  circulation.  As 
already  stated,  it  consists  of  a  first  stage  in  which  there  is 
progressive  enfeeblement  of  the  lower  extremities,  saddle-back, 
and  waddling  gait.  This  stage  may  last  a  few  weeks,  months, 
or  even  a  year  before  the  commencement  of  the  next  stage. 
The  second  period  is  characterised  by  apparent  hypertrophy  of 
a  certain  number  of  muscles,  usually  beginning  in  those  of  the 
calf,  and  extending  gradually  to  other  muscles  of  the  trunk 
and  upper  extremities.  Increase  in  the  volume  of  some  muscles 
is  always  accompanied  by  atrophy  of  others.  This  stage  of 
muscular  hypertrophy  continues  to  increase  progressively,  and 
attains  its  maximum  in  degree  and  extent  about  eighteen 
months  from  the  beginning  of  the  second  stage  of  the  disease  ; 
the  symptoms  then  remain  stationary  for  two,  or  three,  and 
sometimes  for  many  years. 

The  third  stage  of  the  disease  is  now  ushered  in  by  a  still 
further  enfeeblement  of  the  muscles  already  affected,  and  by 
the  extension  of  the  paralysis  to  the  superior  extremities.  Ab- 
duction and  elevation  of  the  arm  is  at  first  rendered  difficult, 
then  impossible,  and  by-and-by  the  paralysis  gradually  im- 
plicates the  other  movements  of  the  arm. 

The  child,  now  probably  arrived  at  the  age  of  puberty,  enters 
upon  the  last  stage  of  the  disease.  The  slight  power  of  move- 
ment of  which  he  was  capable  during  the  previous  period 
becomes  gradually  lost,  so  that  he  can  only  sit  in  a  chair  or 
recline  on  a  couch.  The  patient  may  continue  to  live  for  a 
long  time  in  this  condition,  but  eventually  death  supervenes 
from  exhaustion  or  some  intercurrent  malady. 

§  433.  Diagnosis. — When  the  disease  is  thoroughly  estab- 
lished there  can  scarely  be  any  possibility  of  mistaking  it  for 
any  other  affection.  The  diseases  which  are  most  nearly  related 
to  it  are  infantile  paralysis  and  progressive  muscular  atrophy 
in  the  infant.  True  muscular  hypertrophy  may  also  be  mis- 
taken for  the  disease,  and  a  likely  condition  to  be  confounded 
with  it  is  a  late  development  of  the  power  of  muscular  co- 
ordination and  walking  in  children,  especially  when  combined 
with  a  cerebral  lesion,  as  in  cases  of  idiotcy. 


200  SYSTEM  DISEASES  OF  THE 

The  invasion  of  infantile  paralysis  is  sudden  and  accompanied 
with  fever,  and  the  distribution  of  the  paralysis  is  totally  different 
from  that  of  the  pseudo-hypertrophic  variety.  Sometimes  the 
paralysis  is  limited  to  a  few  muscles  or  to  an  entire  limb,  at 
other  times  it  is  hemiplegic,  crossed,  paraplegic,  or  general. 
The  muscles  which  are  least  injured  recover  completely,  while 
others  atrophy,  and  in  the  latter  there  is  very  early  and 
decided  diminution  of  electro-muscular  contractility. 

Progressive  muscular  atrophy  in  the  child  usually  begins 
between  the  age  of  five  and  seven.  Some  of  the  facial 
muscles,  principally  the  orbicularis  oris  and  zygomatic!,  become 
atrophied.  After  a  stationary  period  of  some  years  the  atrophy 
extends  successively  to  the  muscles  of  the  upper  limbs  and 
trunk,  and  the  lower  extremities  are  not  affected  until  a  more 
advanced  period.  The  muscles  are  invaded  irregularly,  and 
as  the  degree  of  paralysis  is  always  proportional  to  the  amount 
of  atrophy  this  gives  rise  to  various  deformities  of  the  trunk 
and  limbs.  When  the  atrophy  attacks  the  extensor  muscles  of 
the  trunk  and  some  of  the  muscular  groups  of  the  lower  ex- 
tremities, as  in  the  case  of  Charlotte  A ,  already  described, 

progressive  muscular  atrophy  is  by  no  means  easy  to  distinguish 
from  pseudo-hypertrophic  paralysis. 

In  making  a  diagnosis,  the  main  reliance  must  then  be 
placed  on  the  history  of  the  case,  the  progress  of  the  symptoms, 
and  a  microscopic  examination  of  portions  of  the  muscles  of 
the  calf  withdrawn  by  the  trocar. 

Simple  muscular  hypertrophy  may  be  distinguished  from 
pseudo-hypertrophic  paralysis  by  the  history  of  the  case,  the  ab- 
sence of  paralysis  and  of  the  special  symptoms  of  the  latter  disease, 
and  if  necessary  by  a  microscopic  examination  of  the  muscle. 

In  late  development  of  the  muscular  co-ordination  in 
children  the  feet  are  not  planted  widely  apart,  and  there  is  no 
saddle-back  or  waddling  walk.  When  want  of  co-ordination  is 
combined  with  idiotcy  there  is  a  flow  of  saliva  from  the  half- 
open  mouth,  and  the  tendinous  reflexes  are  generally  exag- 
gerated in  the  lower  extremities. 

§  431.  Morbid  Anatomy. — The  first  examination  of  the  con- 
dition of  the  muscles  in  this  disease  was  made  in  Germany  by 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  201 

Greisinger  and  Billroth,  who  excised  in  a  young  living  sub- 
ject a  portion  of  the  left  deltoid  which  was  completely  paralysed 
and  hypertrophied.  Duchenne,  however,  not  liking  to  under- 
take such  a  serious  operation,  invented  a  small  instrument, 
which  he  called  his  "  Emporte  piece  histologique,"  and  which 
enabled  him  to  obtain  minute  portions  of  muscular  tissue  from 
the  living  subject.  A  modification  of  this  instrument,  first 
proposed  by  Dr.  Ord  (Med.  Chir.  Transac,  vol.  Ivii.,  1874),  and 
made  by  Hawksley,  London,  is  generally  used  in  this  country 
for  the  purpose.  But  after  repea,tedly  using  Dr.  Ord's  trocar  in 
various  diseases,  I  am  quite  satisfied  that  the  relations  which 
the  different  elements  of  the  diseased  muscle  bear  to  one 
another  are  not  always  accurately  represented  by  the  fragment 
of  tissue  withdrawn  by  the  instrument.  Charcot  indeed  sug- 
gests that  Duchenne's  instrument  will  withdraw  islets  of  con- 
nective tissue,  inasmuch  as  it  will  seize  the  fat  cells  with 
greater  difficulty;  and,  judging  from  my  experience  of  Dr. 
Ord's  trocar,  the  objection  is  valid. 

The  happy  idea  occurred  to  Dr.  Leech  that  an  instrument 
might  be  constructed  which  would  withdraw  a  portion  of  the 
muscle  by  cutting  instead  of  by  tearing;  and  Hawksley  has 
made  one  at  his  suggestion,  which  answers  the  purpose 
admirably.  The  first  muscular  change  which  takes  place  in 
this  disease  consists  of  an  increase  of  the  connective  tissue 
which  separates  the  muscular  bundles  from  one  another,  so  that 
the  sheaths  of  the  muscular  bundles  become  greatly  thickened. 
There  is  also  a  corresponding  increase  of  the  connective  tissue 
which  passes  between  the  fibres  themselves.  The  compara- 
tively thick  masses  of  tissue  which  now  separate  the  fibres  from 
one  another  consist  of  fibres  arranged  parallel  to  the  long  axes 
of  the  muscular  bundles,  mixed  with  a  considerable  number  of 
embryonic  cells.  In  this  early  stage  the  muscular  fibres  them- 
selves do  not  appear  to  undergo  any  very  manifest  changes, 
except  that,  according  to  Duchenne,  their  transverse  striation 
becomes  fainter,  while  the  longitudinal  striation  becomes 
more  marked.  The  transverse  striation  is,  however,  generally 
quite  distinct  until  a  late  period  of  the  disease,  Duchenne 
regarded  the  proliferation  of  the  connective  tissue  as  the  chief 
cause  of  the  increased  size  of  the  muscle ;  hence  he  called  the 


202  SYSTEM  DISEASES  OF   THE 

disease  "paralysie  myoscUrosique ;"  but  other  authors  believe 
that  the  muscle  does  not  increase  much  in  volume  until  the 
second  stage  of  the  change  occurs.  This  stage  consists  of  the 
development  of  fat  cells  in  the  connective  tissue  and  also  in  the 
newly-formed  fibrous  tissue,  whereby  the  muscular  fibres  become 
widely  separated  from  one  another.  The  muscular  fibres  now 
become  atrophied  and  begin  to  disappear.  They  become  nar- 
rower, and  indeed  a  single  fibre  varies  in  diameter  at  different 
points  in  its  length.  The  transverse  striation  may  sometimes 
disappear  in  the  narrower  fibres,  and  be  replaced  by  granules 
distributed  uniformly  through  them.  Much  of  the  fibrous  tissue 
surrounding  the  fibres  contains  oat-shaped  nuclei,  which  are  sup- 
posed by  some  to  be  derived  from  the  empty  sheaths  of  muscular 
fibres  (Clarke,  Gowers).  After  a  time  both  the  muscular  fibres 
and  the  newly- formed  fibroid  tissue  completely  disappear,  and 
the  entire  muscle  is  represented  by  fat  cells  like  those  of  an  ordi- 
nary lipoma.  The  fat  may  subsequently  become  absorbed,  and 
connective  tissue,  with  perhaps  a  few  traces  of  muscular  fibres, 
is  all  that  is  left. 

Condition  of  the  Nervous  System. — The  brain  and  spinal 
cord  have  been  examined  in  several  patients  who  died  from  this 
disease,  but  the  examinations  possess  no  real  value  except  in 
two  or  three  instances.  Even  in  the  case  reported  by  Eulenburg, 
where  the  cord  was  examined  with  great  care  by  such  a  com- 
petent observer  as  Cohnheim,  it  has  been  justly  objected  by 
Charcot  that  delicate  lesions  like  atrophy  of  the  motor  cells 
might  escape  detection,  inasmuch  as  the  cord  was  examined  in 
the  fresh 'condition,  or  only  after  imperfect  hardening.  If  this 
objection  be  valid,  when  urged  against  an  examination  con- 
ducted by  Cohnheim,  how  much  more  true  does  it  become  when 
either  no  microscopic  examination  or  only  a  very  imperfect  one 
was  made.  In  one  of  the  cases  collected  by  Duchenne  the 
patient  died  in  February,  1871,  and  his  brain  and  spinal  cord 
were  carefully  examined,  both  in  the  fresh  state  and  after 
hardening  in  chromic  acid.  Portions  were  forwarded  to  Charcot, 
Yulpian,  and  Lockhart  Clarke,  and  no  abnormal  appearances 
were  detected.  A  large  number  of  sections  of  the  cord,  at 
different  levels  of  the  cervical  and  dorsal  regions,  were  made  by 
M.  Pierret,  and  coloured  by  carmine,  but  neither  Charcot  nor 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  203 

he  could  detect  any  trace  of  disease.  M.  Earth  examined  the 
cord  in  the  case  of  a  man  forty-four  years  old,  who  suffered 
from  muscular  pseudo-hypertrophy,  and  found  partial  de- 
generation of  the  antero-lateral  columns,  and  diminution  of  the 
number  of  ganglion  cells  in  the  anterior  horns  of  the  cord. 
Charcot,  however,  justly  points  out  that  the  clinical  characters 
of  this  case  were  more  like  amyotrophic  lateral  sclerosis  than 
pseudo-hypertrophic  paralysis. 

The  most  important  case  hitherto  examined  is  the  one 
reported  by  Drs.  Lockhart  Clarke  and  Gowers,  in  which 
"  varied  and  extensive  "  lesions  of  the  cord  were  found.  These 
lesions  were  so  numerous  that  only  the  most  important  of  them 
can  be  mentioned  here.  The  changes  began  on  a  level  with 
the  origin  of  the  second  cervical  pair  of  nerves,  and  consisted 
of  "  disintegration  of  the  lateral  grey  network  which  is  so  con- 
spicuous in  the  region  between  the  caput  cornu  posterioris  and 
the  tractus  intermedio-lateralis,  and  through  which  the  spinal 
accessory  nerve  makes  its  way  into  that  tract."  "  One^half  of 
the  anterior  white  commissure  was  entirely  destroyed."  In  the 
lower  part  of  the  cervical  region  there  was  disintegration  of 
some  of  the  "  posterior  nerve  roots  near  the  entrance  into  the 
caput  cornu  posterioris,"  and  both  the  lateral  and  posterior 
white  columns  were  in  many  sections  damaged  by  sclerosis. 
In  the  upper  portion  of  the  dorsal  region  "the  changes  were 
less  frequent  and  extensive,  but  here  and  there  the  anterior 
white  commissure  was  partially  destroyed,"  The  lesions  were 
"  most  extensive  and  striking"  at  the  lower  part  of  the  dorsal 
region  and  the  commencement  of  the  lumbar  enlargement. 
The  central  and  lateral  parts  of  the  grey  substance  on  each 
side  were  severely  damaged  by  softening  and  disintegration. 
In  the  middle  part  of  the  lumbar  enlargement  the  lesions 
were  less  serious,  but  in  the  lower  portions  and  in  the  conus 
medullaris  the  lesions  of  the  grey  substance  were  again  more 
extensive  and  severe.  "  The  central  part  of  the  anterior  cornu 
and  the  outer  part  of  the  cervix  cornu  posterioris  were  very 
much  damaged  by  continuous  disintegration."  The  large  nerve 
cells  in  the  anterior  cornua  were  much  diminished  in  number, 
and  the  few  remaining  cells  were  atrophied  and  contained  an 
excess  of  pigment. 


204  SYSTEM   DISEASES   OF  THE 

The  following  abstract  of  aa  important  case  of  this  disease, 
in  which  a  post-mortem  examination  was  obtained,  I  owe  to 
the  kindness  of  Dr.  Leech,  who  is  preparing  a  series  of  in- 
teresting cases  of  this  disease  for  publication. 

R.  J ,  aged  seven,  came  under  Dr.  Leech's  care  at  the  Manchester 

Infirmary  on  the  20th  of  September,  1877,  with  the  well-known  symptoms 
of  pseudo-hypertrophic  paralysis.  His  walk  and  method  of  rising  from 
the  recumbent  posture  were  quite  characteristic,  and  lordosis  was  well 
marked.  The  calves  of  the  legs  were  unduly  large  and  firm,  the  arms 
and  thighs  thin,  distinctly  atrophied,  the  other  parts  of  the  body  were 
badly  nourished  though  not  definitely  wasted.  The  pectoral  muscles  were 
the  most  reduced  in  size  and  strength,  whilst  the  deltoids  were  firm  and 
large  as  compared  with  the  other  muscles  of  the  shoulder  and  arm. 

The  boy  could  stand,  though  not  without  difficulty,  for  the  heels  could 
only  be  brought  to  the  ground  with  effort  ;  his  power  of  locomotion  was  of 
course  limited,  yet  he  could  easily  walk  across  a  wide  ward  without 
falling.  The  boy  had  appeared  quite  healthy  till  he  began  to  walk.  When 
two  years  old  it  was  noticed  that  he  was  not  so  firm  on  his  legs  as  his 
brothers  and  sisters  had  been.  As  he  advanced  in  age  muscular  weakness 
became  more  apparent.  He  fell  constantly  and  had  difficulty  in  rising  ; 
he  could  only  get  upstairs  with  the  aid  of  his  arms.  At  three  years  of 
age  the  boy's  limbs  had  lost  their  plumpness.  The  increase  in  the  size 
of  the  calves  of  the  legs  was  not  noticed  till  sis  months  before  he  came 
into  the  Infirmary.  It  does  not  appear  that  any  other  member  of  the 
family  had  been  similarly  affected. 

The  boy  continued  under  my  care  two  years,  and  then  died  of  bron- 
chitis. A  slight  amount  of  wasting  went  on  in  all  parts  of  the  body  during 
this  time,  and  the  loss  of  muscular  power  was  considerable. 

Eighteen  months  before  he  died  he  became  unable  to  walk  or  stand, 
and  the  rest  of  his  life  was  passed  in  a  chair  or  lying  down.  For  the  last 
six  months  he  was  unable  to  extend  fully  his  legs,  and  sat  in  a  bowed 
position  owing  to  the  weakness  of  the  muscles  of  his  back.  The  calves 
of  his  legs  decreased  slightly  in  size,  but  continued  large  as  compared 
with  the  other  parts  of  the  body. 

A  post-mortem  was  made  thirty-six  hours  after  death.  The  muscles 
had,  for  the  most  part,  lost  their  normal  appearance,  and  were  of  a  light 
yellowish  brown  colour.  In  some  places  it  was  difficult  to  distinguish 
them  from  connective  tissue.  This  was  specially  the  case  with  the  pectoral 
muscles.  The  gastrocnemius  looked  on  section  like  dark-coloured  fatty 
tissue.  In  taking  out  the  spinal  cord  a  very  distinct  difference  was 
noticed  between  the  condition  at  the  erector  spinse  in  the  lumbar  and 
upper  dorsal  region.  In  the  former  the  muscles  had  a  connective-tissue- 
like appearance  ;  towards  the  mid-dorsal  region  they  became  darker  and 
redder,  and  in  the  upper  dorsal  region  had  the  ordinary  appearance  of 
muscular  tissue. 


SPINAL   CORD  AND  MEDULLA   OBLONGATA. 


205 


The  muscles  in  the  cervical  region  had  the  same  appearance  as  those 
in  the  upper  dorsal.  The  rhomboids,  levator  anguli  scapulae,  and  tra- 
pezius were  distinctly  altered  in  colour  and  texture,  the  upper  part  of 
the  trapezius  being  the  least  affected. 

The  microscope  seemed  to  show  that  nearly  all  the  muscular  tissue  in 
the  body  was  affected,  for  even  in  that  taken  from  the  upper  dorsal  region 
which  looked  healthy  a  distinct  increase  of  connective  tissue  between  the 
fibres  was  evident. 

In  the  muscles  which  appeared  to  the  naked  eye  most  changed,  such 
as  the  pectorals,  the  new  connective  tissue  growth  was  very  much  more 
extensive,  all  the  fibres  of  the  primitive  fasciculi  being  separated  by  it, 
whilst  here  and  there  single  fibres  ran  alone  widely  separated  by  connec- 
tive tissue  from  their  companions. 

Here  and  there  rows  of  fat  cells  appeared  sometimes  between  muscular 

Fig.  172. 


Fig.  172  (Young).  Muscular  Fibres  in  various  stages  of  degeneration,  from  a  case  of 
Pseudo-hyj)ertrophic  Paralysis.  —  a,  Muscular  fibre  only  slightly  changed, 
showing  increase  of  the  muscle  corpuscles,  and  indistinctness  of  the  transverse 
striation  in  certain  parts  of  its  length;  h,  the  same  as  a,  but  more  atro- 
phied ;  c,  muscular  fibre  greatly  atrophied,  and  presenting  nuclei  at  intervals ; 

d,  atrophied  muscular  fibre,  with  its  transverse  striation  unusually  distinct ; 

e,  atrophied  fibre  surrounded  by  a  fibrillated  connective  tissue  rich  in 
nuclei ;  /  and  g,  muscular  fibres  from  the  erector  spinse,  which  manifested  the 
greatest  changes  to  the  naked  eye.  These  fibres  appear  to  have  undergone  a 
hyaline  change,  but  their  transverse  striation  is  still  faintly  visible.  The  fibres 
often  tapered  to  a  point,  sometimes  at  one  and  sometimes  at  both  ends. . 


206 


SYSTEM   DISEASES   OF  THE 


fibres,  sometimes  surrounded  by  connective  tissue,  and  in  places  accumu- 
lations of  fat  cells  were  met  with  instead  of  single  rows. 

In  the  gastrocnemius  muscle  the  same  condition  was  present,  but  the 
fat  cells  were  much  more  abundant  and  formed  loose  accumulations  of 
adipose  tissue  amid  the  muscular  fibres  and  connective  tissue. 

In  all  the  muscles  the  fibres  were  distinctly  narrowed,  and  the  nuclei 
of  the  sarcolemma  were  greatly  increased  in  number,  but  the  striation  of 
the  fibres  was  for  the  most  part  not  interfered  with  and  was  often  unusually 
distinct,  even  in  fibres  which  had  undergone  a  high  degree  of  atrophy 
{Fig.  172,  G,  d).  The  annexed  diagram  {Fig.  172)  represents  the  more 
usual  appearances  presented  by  the  altered  muscular  fibres. 

In  very  few  of  the  fibres  was  granular  change  met  with,  whilst  hardly 
any  good  examples  of  true  fatty  change  were  seen. 

The  decrease  in  the  diameter  of  the  muscular  fibre  seemed  most  marked 
in  the  muscles  which  were  most  changed  to  the  naked  eye.   In  the  erector 

Fig.  173. 


Fig.  173  (Young).  Transverse  Section  from  the  lower  half  of  the  Lumbar  Enlarge- 
ment of  the  Spinal  Cord,  from  a  case  of  Pseudo-hypertrophic  Paralysis. — A, 
Anterior  grey  horn  ;  P,  Posterior  grey  horn  ;  cc,  central  canal ;  i,  internal, 
a,  anterior,  al,  antero-lateral,  pi,  postero-Iateral,  c,  central  group  of  ganglion 
cells  ;  m,  median  area. 

spinse  from  the  upper  dorsal  region,  for  example,  it  was  hardly  manifest  ; 
whilst  many  of  the  fibres  of  the  pectoral  muscle  were  reduced  to  one-sixth 
of  their  normal  diameter.  The  narrowing  of  the  muscular  fibres  seemed 
indeed  proportionate  to  the  extent  of  the  development  of  the  new  con- 
nective tissue. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA. 


207 


Dr.  Leech  kindly  sent  the  spinal  cord  to  me  for  examination.  In  the 
lumbar  region  the  normal  loose  and  spongy  texture  of  the  central  column 
was  replaced  by  a  somewhat  dense  and  fibrillated  tissue,  in  which  no  trace 
of  ganglion  cells  could  be  found.  The  blood-vessels  were  enlarged,  and 
their  walls  thickened.  In  the  anterior  grey  horns  the  ganglion  cells  had 
completely  disappeared  from  the  median  area,  the  anterior  group,  and  the 
margins  of  all  the  other  groups  {Fig.  173).  The  ganglion  cells  could  be 
distinctly  seen  in  the  internal  group  {Fig.  173,  i),  but  they  were  atrophied, 
and  only  a  few  of  their  processes  could  be  discovered,  and  the  central 
group  {Fig.  173,  c)  presented  one  or  two  cells  only  which  were  not  distinctly 
atrophied.  The  central  portions  of  the  antero-lateral  and  postero-lateral 
{Fig.  173,  al,  pi)  groups,  however,  contained  some  cells  which  appeared 

Fig.  174, 


-  -,  r^^ 


cr-^ 


Fig.  174  (Young).  Transverse  Section  from  the  middle  of  the  Dorsal  Region  of  the 
Spinal  Cord,  from  a  case  of  Pseudo-hypertrophic  Paralysis.  — vc,  The  vesicular 
column  of  Clarke.  The  other  letters  indicate  the  same  as  the  corresponding 
letters  in  Fig.  VIZ. 


in  every  respect  normal,  but  others  contained  an  excess  of  pigment,  while 
the  marginal  cells  were  decidedly  atrophied. 

In  the  dorsal  region  the  central  column  presented  the  same  general 
appearances  as  in  the  lumbar  enlargement.  The  disease  extended  into 
the  anterior  grey  horn  in  the  dorsal  region  chiefly  in  the  area  which 
lies  between  the  antero-lateral  and  postero-lateral  groups  {Fig.  174,  al,pl) — 
the  medio-lateral  area.  The  ganglion  cells  of  the  postero-lateral  group 
were  atrophied  and  destitute  of  processes  to  a  very  marked  degree.     The 


208 


SYSTEM  DISEASES   OF  THE 


cells  could  not  be  seen  in  the  anterior  {Fig.  174,  a)  nor  in  the  central  group, 
but  those  of  the  internal  and  antero-lateral  groups  were  distinctly  visible. 
Many  of  the  latter,  however,  contained  an  excess  of  pigment,  and  appeared 
to  have  lost  a  considerable  number  of  their  processes.  The  cells  of  the 
vesicular  column  of  Clarke  appeared  normal  or  only  slightly  altered. 

In  the  cervical  region  the  central  column  also  presented  the  same 
general  appearances  as  the  other  portions  of  the  cord  just  examined.  In 
the  lower  half  of  the  cervical  enlargement,  however,  the  median  area  of 
the  anterior  horns  contained  beautiful  healthy  cells,  and  it  contrasted 
strongly  in  this  respect  with  the  median  area  in  the  lumbar  enlargement. 
The  internal  group  of  cells  were  also  healthy,  while  healthy  cells  were 
seen  in  the  anterior  group.  The  marginal  cells  of  the  central,  antero- 
lateral, and  postero-lateral  groups  were,  however,  atrophied,  while  many 
of  them  had  disappeared.  In  the  upper  end  of  the  cervical  enlargement 
the  central  and  antero-lateral  groups  appeared  to  have  been  more  diseased 
than  any  other  portion  of  the  anterior  horn  {Fig.  175,  c,  al). 


Fig.  175  (Young).  Transverse  Section  from  the  upper  half  of  the  Cervical  Enlargement 
of  the  Spinal  Cord,  from  a  case  of  Pseudo-hypertrophic  Paralysis.  The  letters 
indicate  the  same  as  the  corresponding  letters  in  Fig.  173. 


§  435.  Pathology. — This  disease  is  so  frequently  associated 
with  obtuseness  of  the  mental  faculties,  or  with  idiotcyand  cre- 
tinism, that  Duchenne  was  at  first  inclined  to  believe  that  the 
muscular  changes  resulted  from  cerebral  disease.  More  extended 


SPINAL  CORD  AND  MEDULLA   OBLONGATA.  209 

observation,  however,  soon  showed  that  this  affection  frequently 
exists  independently  of  any  cerebral  lesion.  The  dilatation  of 
the  capillaries  of  the  skin  over  the  afiected  muscles,  and  the 
frequent  elevation  of  the  superficial  temperature  of  the  limbs, 
as  compared  with  that  of  the  trunk,  have  led  some  pathologists 
to  think  that  the  primary  lesion  is  situated  in  the  vaso-motor 
nervous  system,  but  no  additional  facts  have  been  discovered 
to  verify  this  supposition.  There  still  remains  the  question, 
whether  the  disease  is  primarily  in  the  muscles,  or  in  that 
part  of  the  nervous  system  which  controls  their  nutrition. 
Charcot  and  Friedreich  regard  the  muscular  lesion  as  the 
essential  one.  Friedreich,  however,  looks  upon  progressive 
muscular  atrophy  also  as  primarily  a  muscular  disease;  and, 
indeed,  he  considers  the  two  diseases  as  essentially  the  same, 
although  each  is  somewhat  modified  by  circumstances. 

Charcot,  on  the  other  hand,  who  believes  that  progressive 
muscular  atrophy  is  primarily  a  nervous  disease,  regards  pseudo- 
hypertrophic paralysis  as  a  primary  disease  of  the  muscular 
tissue.  Charcot  grounds  his  opinion  mainly  on  the  fact  that  he 
could  detect  no  lesion  in  the  cord  which  he  had  examined  for 
Duchenne  ;  and  considering  how  thoroughly  competent  he  is  to 
decide  such  a  point,  it  must  be  admitted  that  the  objection 
against  regarding  the  disease  as  of  nervous  origin  is  an  ex- 
ceedingly strong  one. 

Passing  over  the  case  observed  by  Barth,  as  not  being  an 
undoubted  example  of  the  disease  under  consideration,  the  case 
observed  by  Drs.  Lockhart  Clarke  and  Gowers  speaks  strongly 
in  favour  of  the  nervous  origin  of  the  affection.  It  is  evident, 
from  the  description,  that  extensive  changes  had  occurred  in 
the  central  column,  and  the  postero-lateral  group  of  cells  of  the 
anterior  cornua,  throughout  the  greater  part  of  the  lumbar 
enlargement  and  lower  dorsal  region  of  the  cord.  I  observe, 
however,  that  even  Dr.  Gowers  has  abandoned  the  nervous 
theory  of  pseudo-hypertrophic  paralysis,  and  we  must  leave  the 
question  an  open  one  at  present. 

In  any  subsequent  case  the  condition  of  the  ganglion  cells  of 

the  postero-lateral  and  medio-lateral  groups  in  the  lumbar  and 

dorsal  regions  of  the  cord  should  be  carefully  examined.    In  the 

spinal  cord  which  I  examined  the  changes  found  in  the  central 

o  , 


210  SYSTEM  DISEASES   OF  THE  SPINAL   CORD. 

grey  column  and  anterior  grey  horns  corresponded  so  closely 
with  those  observed  in  progressive  muscular  atrophy,  that  I  see 
no  reason  to  question  the  essential  unity  of  the  two  diseases. 

Even  if  pseudo-hypertrophic  paralysis  were  proved,  beyond 
doubt,  to  be  a  primary  disease  of  the  muscular  tissue,  yet  the 
clinical  affinities  between  it  and  progressive  muscular  atrophy  ■ 
are  so  numerous  as  to  justify  us  in  considering  the  diseases  in 
the  same  category. 

§  436.  Prognosis. — In  two  cases  under  the  care  of  Duchenne, 
the  disease  was  arrested  in  its  first  stage  by  treatment.  This 
shows  that  the  prognosis  is  not  absolutely  hopeless.  When,  how- 
ever, the  second  period,  or  that  of  apparent  hypertrophy  of  the 
muscles,  has  set  in,  the  case  is  in  all  probability  beyond  the 
reach  of  treatment,  and  it  is  still  more  surely  progressive  and 
fatal  in  the  period  of  atrophy. 

§  437.  Treatment. — Duchenne  relied  mainly  on  the  faradic 
current  in  the  two  cases  which  he  cured.  Baths,  friction,  and 
shampooing  were  also  employed  as  subsidiary  means.  The  gal- 
vanic current  applied  over  the  sympathetic  nerves  has  been 
recommended  by  Benedikt,  but  this  method  has  not  been  found 
to  possess  any  advantage  in  the  hands  of  others.  An  improvement 
in  motor  power  took  place  in  a  case  under  the  care  of  Rosenthal 
by  the  application  of  the  constant  current  several  times  a  week 
to  the  nerves  of  the  hypertrophied  muscles,  along  with  the 
daily  use  of  rubbing  and  the,  cold  plunge  bath.  Gymnastics 
and  mountain  air  aided  the  treatment.  The  iodides  of  iron 
or  of  potassium,  or  when  there  are  cerebral  symptoms  the 
bromide  of  potassium  may  be  tried ;  but  the  remedies  which 
promise  to  do  most  good  are  the  so-called  tonics.  Arsenic, 
Parrish's  chemical  food,  phosphorus,  and  cod-liver  oil,  and  in 
some  cases  strychnia  or  nux  vomica,  may  be  tried. 


211 


CHAPTER    IV. 


I.— SYSTEM   DISEASES    OF    THE    SPINAL    CORD    AND 
MEDULLA   OBLONGATA. 

(ID     LEUCOMYELOPATHIES. 


1,    Progressive  Locomotor  Ataxy. 

(Tabes  Dorsalis ;  Grey  Degeneration,  or  Sclerosis  of  the  Posterior  Columns.) 

§  438.  Definition. — Locomotor  ataxy  is  a  chronic  disease, 
characterised  by  the  progressive  abolition  of  the  power  of 
co-ordinating  the  general  movements  concerDed  in  locomotion, 
and  other  voluntary  actions,  but  without  distinct  loss  of  mus- 
cular power. 

§  439.  History. — An  accurate  knowledge  of  this  disease,  which  is  now 
so  well  known,  is  of  comparatively  recent  date,  although  obscure  inti- 
mations of  the  affection  may  even  be  found  in  the  writings  of  the  Greek 
physicians.  In  1679  Bonnet  appears  to  have  revived  the  name  of  tabes 
dorsalis,  which  had  fallen  into  disuse,  and  he  also  associated  the  symptoms 
with  anatomical  changes,  principally  atrophy  of  the  spinal  cord.  Indi- 
vidual observations  of  the  disease  may  be  found  in  the  works  of  OUivier, 
Cruveilhier,  Hutin,  and  Stanley,  and  the  phenomena  of  ataxy  were 
described  with  great  accuracy  by  Bell,  Nasse,  and  Landry  ;  but  W.  Horn 
was  the  first  to  give  an  accurate  account  of  the  course  and  symptoms  of 
ataxy,  and  to  recognise  it  as  a  distinct  type  of  disease.  Horn's  description 
appeared  in  1827,  and  the  classical  monograph  of  Romberg  was  published 
in  1840,  while  the  anatomical  investigations  of  W.  and  E.  Horn,  Jacoby, 
Froriep,  and,  above  all,  the  microscopic  researches  of  Rokitansky  and 
Tiirck  proved  that  the  symptoms  were  caused  by  grey  degeneration  of 
the  posterior  columns  of  the  cord.  The  disease  was  most  accurately 
described  in  England  in  1847  by  Todd,  who  directed  special  attention 
to  the  fact  that  the  characteristic  symptoms  were  due  to  want  of  power 
in  co-ordinating  movements,  and  not  to  deficiency  of  voluntary  power. 
French  physicians  had  completely  neglected  the  affection  until  Duchenne 


212  SYSTEM  DISEASES   OF  THE 

published  his  memoir  in  1858,  aud  so  profound  was  the  impression  pro- 
duced by  the  exhaustive  analysis  aud  accurate  descriptions  of  this  author 
that  he  was  for  a  long  time  regarded  as  the  discoverer  of  the  disease. 
The  writings  of  Duchenne  and  Trousseau  contributed  more  than  any 
others  to  obtain  for  this  affection  the  recognition  of  the  profession. 
Duchenne  did  not  make  any  contribution  to  the  pathological  anatomy  of 
the  disease,  but  he  thought  that  the  deficiency  of  motor  co-ordination 
must  be  dependent  upon  some  structural  or  functional  lesion  of  the 
cerebellum.  He  suggested  that  the  central  morbid  process  began  in  the 
motor  nerves  of  the  eye  and  the  corpora  quadrigemina,  from  which  it 
extended  to  the  superior  peduncles  of  the  cerebellum,  and  lastly  to  the 
cerebellum  itself.  This  view  was  combated  by  Eisenmann,  and  a  lively 
discussion  ensued  which  had  the  effect  of  settling  definitely  that  the  most 
constant  anatomical  lesion  in  locomotor  ataxy  is  grey  degeneration  or 
sclerosis  of  the  posterior  columns  of  the  spinal  cord.  Amongst  the 
authors  who  contributed  to  establish  this  view  may  be  mentioned 
Dumenil,  Bourdon,  Oulmont,  Marrotte,  Charcot  and  Vulpian,  Luys  and 
Carr^  in  France  ;  Rindfieisch,  Westphal,  Friedreich,  and  Leyden  in  Ger- 
many ;  and  Lockhart  Clarke  in  England.  In  its  clinical  relations  the 
disease  has  been  investigated  amongst  others  by  Jaccoud,  Topinard, 
Axenfeld,  Remak,  Spaeth,  Cyon,  Benedikt,  and  many  other  authors. 

The  name  of  the  disease  has  also  undergone  frequent  changes  in  accor- 
dance with  the  prevailing  doctrines  with  regard  to  its  nature.  When  it 
was  regarded  as  being  due  to  atrophy  of  the  spinal  cord,  it  received  the 
name  of  "Atrophia  MeduUse  Spinalis,"  a  name  which  had  to  be  abandoned 
on  more  accurate  histological  investigation.  Wunderlich  called  it  "  Pro- 
gressive Spinal  Paralysis,"  but  this  name  became  untenable  when  it  was 
found  that  the  symptoms  did  not  depend  upon  paralysis  but  on  want  of 
co-ordination.  In  the  present  day  three  names  are  employed  indiflferently 
to  designate  the  disease.  These  are  "  Grey  Degeneration  or  Sclerosis  of 
the  Posterior  Columns  of  the  Cord,"  "  Progressive  Locomotor  Ataxy,"  and 
"Tabes  Dorsalis."  None  of  these  names  are  entirely  free  from  objections, 
but  they  have  got  possession  of  the  field,  and  it  would  occupy  space  to 
very  little  advantage  to  discuss  here  all  objections  which  might  be  urged 
against  them. 

§  440.  Etiology. — The  etiology  of  the  disease  is  very  obscure, 
and  in  many  cases  no  definite  cause  of  it  can  be  traced. 

Hereditary  predisposition  undoubtedly  exercises  a  certain 
amouQt  of  influence  in  its  production.  Locomotor  ataxy  is 
frequently  met  with  in  individuals  whose  nearest  relatives 
are  liable  to  suffer  from  other  nervous  diseases,  such  as 
monomania,  hypochondriasis,  epilepsy,  migraine,  mental  dis- 
eases, or  violent  fits  of  anger  and  drunkenness.     Trousseau 


SPINAL   CORD   AND   MEDULLA  OBLONGATA. 


213 


mentions  the  case  of  a  patient  suffering  from  advanced 
locomotor  ataxy,  whose  uncle  and  aunt  were  insane,  and  who 
had  one  brother  ataxic  and  another  hemiplegic.  He  also 
mentions  the  case  of  another  patient  who  had  been  ataxic 
for  upwards  of  twenty  years,  but  whose  intellect  was  perfectly 
clear.  His  father  committed  suicide;  and  his  two  sons  laboured 
under  peculiar  nervous  affections,  one  having  singular  muscular 
spasms,  and  the  other  being  irresistibly  compelled  to  shriek  in 
a  most  extraordinary  manner  nearly  all  day.  In  other  cases 
the  influence  of  heredity  is  direct  from  the  parent.  Friedreich 
met  with  three  different  families  in  which  several  brothers 
and  sisters  were  attacked  with  the  disease  at  almost  the  same 
age,  while  the  parents  themselves  were  healthy.  Carre  was 
informed  by  an  ataxic  patient  that  seventeen  other  members  of 
her  family  were  affected  by  the  same  disease.  Dr.  Dreschfeld 
has  recorded  an  instance  of  a  family  in  which  five  out  of  fifteen? 
and  Dr.  Gowers  one  in  which  five  out  of  nine  children  were 
affected  with  locomotor  ataxia.  In  many  cases  of  tabes  no 
hereditary  neuropathic  tendency  can  be  traced. 

The  male  is  much  more  liable  to  be  affected  with  the  dis- 
ease than  the  female  sex,  no  doubt  greatly  owing  to  the  fact 
that  men  are  much  more  exposed  than  women  to  the  most 
powerful  exciting  causes  of  the  affection,  such  as  exposure  to 
cold  and  sexual  excesses.  Out  of  149  cases  collected  by 
Eulenburg  128  were  males  and  21  only  females,  so  that  the 
number  of  the  latter  affected  in  proportion  to  the  total  number 
was  barely  14  per  cent.  The  following  table,  given  by  Eulen- 
burg, shows  not  only  the  proportion  between  the  number  of 
males  and  females,  but  the  number  which  occurred  at  various 
ages : — 


Male. 

Female. 

From    0  to  10 

years     . . . 

..     — 

1 

„     10   „   20 

..       2 

— 

„     20   „   30 

..     35 

12 

„     30   „   40 

..     39 

7 

„     40   „   50 

..     47 

1 

„     50   „   60 

..       5 

— 

After  60  years 

..     — 

— 

128  21 

From  this  table  it  will  be  readily  seen  that  locomotor  ataxy 
is  a  disease  of  youth  and  middle  age,  by  far  the  largest  number 


214  SYSTEM  DISEASES   OF  THE 

of  cases  occurring  from  thirty  to  fifty  years  of  age.  The  disease 
is  rare  before  the  twentieth  and  after  the  fiftieth  year. 

Those  who  from  the  nature  of  their  occupation  are  obliged  to 
expose  themselves  to  cold  and  wet. and  to  other  bodily  hardships, 
such,  for  instance,  as  commercial  travellers,  engineers,  soldiers, 
and  sailors,  are  very  liable  to  be  affected  with  locomotor  ataxy. 
It  is  notorious  that  soldiers  are  particularly  liable  to  be  affected 
with  the  disease  after  bivouacing  on  damp  ground. 

Severe  bodily  and  mental  exertion  both  predispose  to  the 
disease  and  act  as  exciting  causes  in  its  production.  The  severe 
struggle  for  existence  to  which  the  inhabitants  of  large  towns 
are  subjected  explains,  perhaps,  why  the  disease  is  relatively 
more  frequent  in  large  cities  than  in  the  country.  The  largest 
number  of  cases  of  tabes  are  probably  caused  by  excessive  bodily 
exertion  and  subsequent  exposure  to  damp  and  cold,  hence  the 
frequency  with  which  tabes  occurs  in  soldiers  after  forced 
marches  in  cold  weather. 

Emotional  disturbances,  such  as  sudden  fright,  continued 
anxiety,  and  repeated  anger,  appear  occasionally  to  be  capable 
of  being  the  starting  point  of  tabes. 

Locomotor  ataxy  is  an  occasional  sequel  of  acute  diseases, 
such  as  typhus,  articular  rheumatism,  acute  pneumonia,  and 
above  all  diphtheria ;  but  it  is  difficult  to  determine  whether 
these  affections  act  as  predisposing  causes  or  whether  they  take 
a  direct  part  in  setting  up  nutritive  changes  in  the  cord. 
Difficult  labours  and  repeated  abortions,  severe  puerperal 
affections,  copious  haemorrhages,  and  long-continued  lactation 
are  mentioned  as  other  causes  of  this  affection.  Syphilis  is 
a  frequent  cause  of  locomotor  ataxy,  although  probably  not  so 
frequent  as  was  at  one  time  supposed. 

At  one  time  sexual  excess  and  onanism  were  regarded  as 
almost  the  only  causes  of  tabes,  and  the  unfortunate  victims  of 
the  disease  were  often  unjustly  suspected  of  leading  secretly 
immoral  lives.  That  sexual  excess,  however,  is  a  very  important 
exciting  cause  of  the  affection  is  shown  by  the  frequency  with 
which  it  occurs  in  men  during  the  period  of  their  greatest 
sexual  activity,  as  well  as  by  the  fact  that  the  disease  has 
been  known  to  follow  immediately  upon  great  sexual  excesses. 
Frequent    pollutions   and   spermatorrhoea   often   precede    the 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  215 

outbreak  of  tabes,  but  whether  these  are  the  cause  of  the 
disease  or  mere  results  of  the  primary  sensory  disturbances 
which  are  so  common  in  the  early  stage  of  the  affection  is 
difficult  to  determine. 

Various  traumatic  injuries  may  be  the  starting  point  of  loco- 
motor ataxy,  and  instances  are  recorded  in  which  the  disease 
soon  followed  a  fracture  of  the  thigh,  a  fall  upon  the  belly,  the 
shock  of  a  gunshot  wound,  and  concussion  of  the  spinal  cord 
(Schulze).  Some  think  that  the  disease  may  also  be  caused  by 
excessive  tobacco  smoking,  but  the  statement  appears  to  be 
unfounded.  In  a  great  number  of  cases  of  tabes  no  recognisable 
cause  can  be  traced  after  the  most  careful  investigation. 

§  441.  Symptoms. — Locomotor  ataxy  generally  begins  with 
a  premonitory  stage,  which  may  extend  over  months  or  years. 
The  most  constant  and  characteristic  premonitory  symptoms  are 
pains  of  a  very  peculiar  and  distressing  kind,  which  are  not  only 
present  during  the  initial  stage,  but  usually  accompany  the 
disease  throughout  its  entire  course,  and  which  may  last  for 
years  without  any  other  symptoms  being  present. 

These  pains  have  been  described  under  the  names  of  general 
neuralgia  or  neuralgic  rheumatism,  and  are  compared  by  the 
patients  to  forked  lightning  darting  through  the  body  (Light- 
ning Pains,  §  53).  The  pains  are  at  other  times  of  a  burning 
character,  and  are  not  unfrequently  confined  to  a  small  well- 
defi.ned  spot  of  the  skin  (Hypersesthetic  Spots,  §  52).  Some- 
times the  pains  may  be  deeply  situated  in  the  soft  parts  or  in 
the  bones,  or  they  may  follow  certain  definite  nerve  tracts,  and 
are  often  regarded  as  rheumatic.  The  nerve  trunks  may  be 
sensitive  to  pressure  during  a  paroxysm.  The  intensity  of  the 
pain  varies  in  different  cases,  and  at  times  patients  suffer  the 
greatest  torture  from  them. 

Pain  in  the  back  is  met  with  occasionally  in  tabes,  and  at 
times  points  painful  to  pressure  may  be  found  on  the  spinous 
or  transverse  processes  of  individual  vertebra,  but  those  are 
rare,  and  appear  also  to  be  quite  unimportant.  Whenever 
there  is  prolonged  or  severe  pain  in  the  back,  it  may  be  suspected 
that  the  disease  is  complicated  by  spinal  meningitis. 

The  feeling  of  a  tight  girdle  round  the  thorax  or  abdomen, 


216  SYSTEM  DISEASES   OF  THE 

which  is  so  frequent  a  symptom  of  many  spinal  affections,  is  also 
a  frequent  symptom  of  locomotor  ataxy  (Girdle  Sensation,  §  51). 
Girdle  pains  may  also  be  felt  round  the  joints  of  the  lower 
extremities,  and  it  is  sometimes  described  as  a  feeling  like  that 
caused  by  a  garter  tied  tightly  below  the  knee.  Sensations 
of  formication,  numbness,  or  of  burning  or  coldness  of  the  skin 
are  frequently  complained  of.  Some  patients  feel  as  if  they 
were  walking  on  wool,  cork,  or  felt  soles;  while  others  feel 
as  if  they  were  walking  on  bladders  of  water.  These  parses- 
thesige  belong  to  the  earliest  stage  of  locomotor  ataxy,  and 
one  or  other  of  them  is  almost  constantly  found  in  the  initial 
stage  of  the  affection.  Hypersesthesia  of  the  skin  is  not  un- 
common in  tabes ;  and  at  times  there  may  be  hypersesthesia 
towards  impressions  of  temperature  and  anaesthesia  of  touch, 
and  at  other  times  anaesthesia  of  the  sense  of  touch  may  be 
accompanied  by  a  high  degree  of  hypersesthesia  towards  im- 
pressions of  pain. 

But  anaesthesia  is  a  much  more  common  symptom  of  loco- 
motor ataxy  than  hypersesthesia.  There  may  be  a  high  degree 
of  anaesthesia  without  the  patients  being  aware  of  it ;  but  after 
a  time  they  find  that  they  no  longer  feel  the  floor  distinctly, 
that  all  articles  which  they  touch  have  a  velvety  feel,  or  that 
they  cannot  hold  small  objects  in  their  fingers.  If  there  is  a 
high  degree  of  anaesthesia,  the  patients  cannot  judge  of  the 
position  of  their  legs  when  in  the  dark.  Anaesthetic  patches 
may  be  found  on  the  soles  of  the  feet,  the  toes,  and  back  of  the 
feet,  and  they  may  be  so  limited  that  they  can  only  be  recog- 
nised by  the  most  careful  examination.  As  a  rule,  however, 
the  diminution  of  sensation  extends  to  the  thigh,  and  even  the 
trunk  and  portions  of  the  upper  extremities,  although  it  is 
generally  most  marked  on  the  legs.  But  the  cutaneous 
anaesthesia  in  locomotor  ataxy  hardly  ever  reaches  the  high 
grade  observed  in  the  later  stages  of  transverse  myelitis,  and 
slow  compression  of  the  cord. 

Every  variety  of  paralyses  of  sensation  and  every  combination 
of  them  are  met  with  in  the  later  stages  of  the  affection; 
but  probably  analgesia  is  the  most  frequent.  Occasionally, 
however,  the  sensibility  to  pain  is  retained,  or  even  increased, 
while  there  is  a  diminution  of  sensibility  to  some  or  all  varieties 


SPINAL   COED   AND   MEDULLA   OBLONGATA,  217 

of  touch;  and,  again,  partial  paralysis  of  the  sense  of  touch  may- 
be combined  with  analgesia  and  hyperalgesia,  or  with  hyper- 
aesthesia  towards  impressions  of  temperature.  At  a  late  period 
of  the  disease  a  distinct  retardation  of  the  conduction  of  sensa- 
tions, especially  of  impressions  of  pain,  is  observed,  and  this  may 
also  be  found  in  the  earlier  stages  of  the  affection.  The 
prick  of  a  needle  frequently  gives  rise  to  a  double  sensation, 
the  first  being  one  of  touch  which  is  conveyed  with  normal 
rapidity,  and  the  second  of  pain  owing  to  the  slowness  with 
which  the  impression  is  conveyed.  Hertzberg  has  demonstrated 
that  in  some  cases  the  sensations  of  touch  and  of  temperature 
are  also  retarded,  although  to  a  less  degree  than  that  of 
pain.  The  sensation  of  pain  also  continues  for  a  relatively 
long  time,  even  when  the  cause  which  has  induced  it  has  been 
of  momentary  diiration,  and  the  highest  degree  is  not  reached 
until  several  seconds  after  the  pain  has  begun  (§  49).  Fischer 
has  recently  observed  that  in  certain  circumscribed  cutaneous 
areas  of  the  foot  the  patient  may  feel  two  points  when  one  only 
is  touching  the  skin,  and  when  two  points  are  in  contact  with 
it  four  or  five  may  be  felt  (Polysesthesia,  §  50).  Disturbances 
of  the  muscular  sensibility  and  muscular  sense  are  frequently 
observed  in  this  affection.  In  the  first  stages  the  alteration 
of  the  muscular  sensibility  consists  of  a  feeling  of  unrest  in 
-the  limbs,  which  prevents  the  patient  from  lying  down  or 
sitting  still  for  any  length  of  time,  a  feeling  which  has  been 
graphically  called  the  fidgets.  It  is  probable  that  the  feeling 
of  fatigue,  which  is  so  frequent  at  the  beginning  of  the  disease, 
is  a  parasthesia  of  the  sensitive  nerves  of  the  muscles.  It 
must,  however,  be  remembered  that  even  in  the  early  stage  of 
the  disease  the  locomotive  movements  require  a  greater  amount 
of  attention  on  the  part  of  the  patient,  and  that  a  much  greater 
effort  is  expended  in  walking  than  in  health. 

As  the  disease  advances,  the  muscular  sense  becomes 
diminished,  and  consequently  the  power  of  recognising  what 
muscles  are  thrown  into  action  is  lessened  in  corresponding 
degree.  When  the  paralysis  of  the  muscular  sense  attains  a 
high  degree,  the  patient  does  not  know  the  position  of  his 
lower  extremities  when  his  eyes  are  closed,  and  is  also  uncertain 
with  regard  to  the  extent  and  direction  of  the  movements  he 


218  SYSTEM  DISEASES  OF  THE 

undertakes;  hence  these  movements,  not  being  under  due  con- 
trol, become  excessive.  This  condition  must,  however,  be  care- 
fully distinguished  from  the  ataxic  movements  about  to  be 
described. 

Although  disturbances  of  sensibility  are  much  more  constant 
and  marked  in  the  lower  than  in  the  upper  extremities,  yet  the 
latter  are  frequently  involved,  especially  in  the  advanced  period 
of  the  disease.  Cases  of  pronounced  ataxia  have  been  described 
by  competent  observers,  in  which  the  most  careful  investigation 
failed  to  detect  the  slightest  trace  of  any  disturbance  of  cuta- 
neous or  muscular  sensibility.  On  the  other  hand,  cases  have 
been  observed  in  which  a  high  degree  of  anaesthesia  was  present, 
but  in  which  the  ataxic  symptoms  were  either  entirely  absent 
or  little  pronounced,  so  that  it  may  be  concluded  that  there  is 
no  constant  relation  between  the  degree  of  ataxy  and  that  of 
cutaneous  or  muscular  anaesthesia. 

The  motor  disturbances  constitute  by  far  the  most  charac- 
teristic features  of  locomotor  ataxy.  The  motor  disturbances 
were  for  a  long  time  thought  to  be  of  a  truly  paralytic  nature, 
but  Todd  and  subsequently  Duchenne  showed  that  the  charac- 
teristic gait  of  ataxy  was  due  to  a  want  of  certainty  and  pre- 
cision in  the  execution  of  movements,  especially  of  combined 
and  complicated  movements ;  while  the  strength  and  certainty 
of  simple  movements  is  not  at  all,  or  only  slightly,  diminished. 
Duchenne  indeed  gave  the  name  of  ataxy  to  the  disease  from 
the  recognition  of  the  circumstance  that  the  characteristic  gait 
depends  on  a  want  of  co-ordination  of  muscular  action  and 
not  upon  true  paralysis.  The  motor  disturbances  almost  always 
begin  in  the  lower  extremities,  and  are  at  first  so  slight  that 
they  can  only  be  recognised  by  careful  examination. 

Static  Ataxia. — During  the  early  stage  of  the  disease  special 
tests,  which  have  the  power  of  increasing  the  motor  inco- 
ordination, are  very  valuable  in  enabling  us  to  determine  the 
true  nature  of  the  affection.  If  the  patient  be  asked  to  stand  up 
and  keep  his  feet  closely  applied  together  along  their  inner 
edges,  he  may  manage  to  maintain  the  erect  posture  with 
moderate  steadiness  when  his  eyes  are  open ;  but  when  they 
are  closed,  he  immediately  oscillates  from  side  to  side,  and  would 
fall  unless  he  open  his  eyes  or  be  supported.    As  the  disorder  of 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  219 

muscular  co-ordination  increases,  standing  without  support,  even 
when  the  eyes  are  open,  becomes  increasingly  difficult,  and 
station  becomes  by-and-by  impossible  without  the  aid  of  sticks 
or  crutches.  When  at  this  stage  the  patient  stands  by  the  sup- 
port of  two  sticks,  it  may  be  observed  that  all  the  extensor 
muscles  of  the  body  are  in  a  state  of  powerful  tonic  contraction. 
The  muscles  of  the  calf  are  strongly  contracted  and  extend  the 
leg  upon  the  foot,  so  that  they  form  an  obtuse  angle  with 
the  other,  the  extensors  of  the  leg  are  contracted  and  ex- 
tend the  thigh  on  the  leg,  the  flexors  of  the  thigh  are  also 
contracted,  and  the  foot  being  fixed,  they  tend  to  extend  the 
trunk  on  the  thigh,  this  tendency  being  greatly  increased  by 
contraction  of  the  gluteal  muscles  and  of  the  erector  spinse.  It 
is  evident  that  if  the  contractions  of  these  muscles  were  un- 
antagonised,  the  patient  could  not  for  a  moment  maintain  the 
erect  posture  but  would  fall  backwards.  The  tendency  to  fall 
backwards  is  counteracted  by  what  appears  to  be  a  voluntary 
contraction  of  the  muscles  which  flex  the  trunk  on  the  thighs. 
By  this  means  the  body  is  bent  forwards,  and  the  line  of  gravity 
falls  in  front  of  the  line  joining  the  centre  of  the  arches  of  the 
feet,  while  the  tendency  to  fall  forwards  is  counteracted  by  the 
support  of  the  two  sticks.  The  attitude  assumed  by  the  patient 
under  these  circumstances  is  characteristic.  The  legs  are  drawn 
backwards  so  as  to  form  an  obtuse  angle  with  the  feet,  the 
thighs  are  extended  on  the  legs,  and  a  plumb-line  let  fall  from 
each  trochanter  falls  considerably  behind  the  heel,  while  the 
forward  inclination  of  the  body  causes  the  buttocks  to  project 
backwards  in  a  marked  manner. 

Ataxic  Gait. — In  the  early  stage  of  the  disease  the  patient 
may  be  observed  to  stagger  a  little  on  getting  up,  especially 
after  sitting  for  a  long  time,  the  staggering  being  greatly  in- 
creased when  the  patient  is  in  the  dark,  closes  his  eyes,  or  has 
to  turn  abruptly  round.  These  phenomena  were  demonstrated 
to  me  in  a  striking  manner  a  few  weeks  ago.  I  was  walking 
on  a  moonlight  night  in  a  garden  with  a  friend  who  has  suffered 
for  upwards  of  twelve  years  from  the  lancinating  pains  of  the 
disease,  and  who  is  now  manifesting  slight  ataxic  symptoms. 
Our  walk  terminated  under  the  shadow  of  a  high  wall  and  tree 
covered  with  thick  foliage.     So  long  as  my  friend  was  in  the 


220  SYSTEM   DISEASES   OF  THE 

moonlight  he  walked  steadily  enough,  but  when  once  we  got 
under  the  deep  shadow  the  staggering  became  very  apparent, 
and  was  much  aggravated  when  we  turned  round. 

In  order  to  test  at  this  early  stage  the  degree  of  precision 
with  which  the  muscular  adjustments  of  the  lower  extremities 
can  be  performed  the  patient  may  be  asked  to  stand  on  one  leg, 
to  run,  or  to  hop,  these  movements  being  more  difficult  to  execute 
than  simple  walking.  He  may  also  be  requested  to  perform 
some  complicated  movement  with  the  extremity,  such  as  to 
describe  the  outline  of  a  circle  on  the  floor  with  the  toe. 

When  the  ataxia  becomes  more  pronounced,  the  gait  becomes 
so  characteristic  that  it  can  be  readily  recognised  without  the 
application  of  any  special  tests.  The  patient  has  now  to  direct 
his  eyes  to  the  ground  and  to  his  feet  while  walking,  and  were 
he  to  close  them  the  movements  of  the  legs  would  become  dis- 
orderly, and  walking  would  be  impossible.  The  patient  assumes 
in  the  erect  posture  the  attitude  already  described,  in  which  the 
trunk  is  bent  forwards  on  the  thighs,  the  feet  are  held  well  in 
advance  of  the  buttocks,  and  the  legs  are  extended  on  the  thighs. 
It  is  impossible  in  this  position  to  advance  the  passive  leg  with 
the  pendulum  movement  characteristic  of  normal  locomotion. 
And,  indeed,  owing  to  the  strong  tonic  contraction  of  the  muscles 
of  the  thigh  and  the  extensors  of  the  foot  which  is  present,  the 
various  segments  of  the  passive  leg  cannot  be  flexed  upon  one 
another  so  as  to  enable  it  to  clear  the  ground  during  its  forward 
movement.  Under  these  circumstances  the  passive  leg  is  pro- 
jected forwards  in  one  piece  by  strong  contraction  of  the  flexors 
of  the  thigh  on  the  trunk,  aided  by  contraction  of  the  abductors 
of  the  thigh.  The  consequence  is  that  the  passive  foot  is  flung 
forwards  and  outwards  with  a  rapid  jerk,  being  subsequently 
brought  down  with  a  thump.  During  this  movement  the  heel 
is  generally  the  last  to  leave  the  ground  and  the  first  to  touch 
it.  The  heel  is,  however,  sometimes  lifted  from  the  ground 
before  the  toe,  as  occurs  in  a  case  under  my  care  at  present. 
As  the  passive  foot  is  being  elevated  a  slight  flexion  occurs  at 
the  knee-joint  and  the  heel  is  elevated  before  the  toe,  but  no 
sooner  is  the  latter  removed  from  the  ground  than  the  leg 
becomes  suddenly  extended  on  the  thigh,  the  foot  is  projected 
forwards  and  outwards,  and  the  heel  is  subsequently  brought 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  221 

down  with  a  thump  in  the  usual  manner.  In  order  to 
enable  the  passive  leg  to  clear  the  ground  during  its  forward 
movement,  the  abductor  muscles  of  the  thigh  on  the  side  of  the 
active  leg  enter  into  strong  contraction,  and  consequently  elevate 
the  pelvis  on  the  side  of  the  passive  leg.  So  strong,  indeed, 
does  the  contraction  of  the  abductors  of  the  thigh  on  the  side 
of  the  active  leg  become  that  the  patient  is  in  danger  of  carrying 
his  centre  of  gravity  too  far  to  that  side.  In  order  to  counteract 
this  tendency  the  upper  part  of  the  body  is  curved  to  the 
opposite  side  by  contraction  of  the  erector  spinae,  and  when  the 
patient  is  able  to  walk  without  sticks,  by  the  arm  on  the  side 
of  the  passive  leg  being  thrust  out  laterally,  and  during  the 
alternate  transference  of  the  line  of  gravity  from  one  foot  to 
the  other  in  walking,  the  trunk  is  moved  from  side  to  side  and 
the  arms  flung  about  like  those  of  a  rope  dancer  in  order  to 
assist  the  patient  to  maintain  his  equilibrium.  When  the 
patient  walks  by  the  aid  of  sticks  the  tendency  to  too  great  a 
lateral  displacement  of  the  centre  of  gravity  towards  the  side  of 
the  active  leg  is  counteracted  by  the  patient  giving  an  outward 
inclination  to  the  sticks,  so  that  he  obtains  a  lateral  support  from 
them.  Patients  who  have  suffered  from  a  high  degree  of  ataxia 
have  been  known  to  walk  long  distances  without  fatigue. 

When,  however,  the  disease  has  made  considerable  progress, 
the  irregularity  and  violence  of  the  movements  soon  exhaust 
the  patient's  strength,  and  he  cannot  take  many  steps  without 
panting  and  being  covered  with  profuse  perspiration.  After  a 
time  the  want  of  co-ordination  becomes  so  great  that  the  main- 
tenance of  the  erect  posture  and  walking  become  impossible. 
If  the  patient  be  supported  by  two  persons  under  the  arms 
whilst,  he  tries  to  walk,  his  legs  are  thrust  backwards  and 
forwards  to  the  right  and  to  the  left  with  the  utmost 
disorder,  so  that  they  are  incapable  of  giving  the  least  support 
to  the  body ;  they  move,  as  Trousseau  remarked,  like  those  of 
a  puppet  or  a  marionnette.  The  muscles  of  the  trunk  may  now 
become  affected,  the  patient  is  unable  even  to  sit  in  a  chair, 
and  remains  confined  to  his  bed.  But  even  in  these  advanced 
cases,  the  patient  when  laid  down  may  be  able  to  resist  passive 
movements  of  the  limbs,  and  to  perform  the  simple  movements 
of  flexion  and  extension  with  scarcely  diminished  power.    When, 


222  SYSTEM  DISEASES   OF  THE 

under  these  circumstances,  the  patient  attempts  to  touch  an 
object  with  the  tip  of  the  foot,  the  line  of  motion  is  irregular 
and  zigzag,  and  disturbed  by  lateral  movements,  while  it  is  quite 
impossible  for  him  to  execute  more  complicated  movements — 
such,  for  instance,  as  are  required  in  describing  an  imaginary- 
circle  with  the  tip  of  the  great  toe. 

At  a  later  period  the  ataxy  appears  in  the  upper  extremities, 
and  cases  have  been  described  by  Friedreich  in  which  the 
ataxy  appears  in  the  upper  simultaneously  with  or  soon  after 
its  first  manifestation  in  the  lower  extremities.  In  the  more 
usual  form  of  the.  disease,  however,  ataxy  of  the  upper 
extremities  is  rare,  and  belongs  to  the  later  manifestations  of 
the  affection.  Ataxy  of  the  upper  extremities  first  manifests 
itself  in  complicated  and  special  movements,  such  as  those 
required  for  writing,  playing  the  piano,  and  other  movements 
requiring  delicacy  of  manipulation.  These  movements  become 
difficult  and  uncertain,  and  the  irregularity  becomes  greater  if 
an  attempt  is  made  to  perform  the  necessary  actions  without 
the  guidance  of  the  eyes.  At  a  later  stage  the  simpler  move- 
ments also  become  irregular  and  ataxic.  If  the  patient  now 
attempts  to  grasp  an  object  before  him,  it  can  only  be  reached 
in  a  roundabout  way  and  with  jerky  interruptions,  and  the  act 
of  grasping  is  performed  in  an  uncertain  and  spasmodic  manner. 
The  slighter  shades  of  ataxy  of  the  upper  extremities  may  be 
tested  by  instructing  the  patient  to  touch  with  closed  eyes  some 
part  of  the  surface  of  the  body,  such  as  the  forehead  or  tip 
of  the  nose  by  the  point  of  the  forefinger  of  each  hand  alter- 
nately, when  the  ataxic  symptoms  declare  themselves  by  the 
inability  of  the  patient  to  touch  the  intended  spot  until  after 
repeated  trials.  A  similar  uncertainty  of  movements  is  observed 
when  the  patient  is  asked  to  transfer  a  small  object  from  one 
hand  to  the  other.  Static  ataxy  at  a  later  period  may  be 
present  in  the  upper  extremities,  so  that  the  patients  can  no 
longer  hold  their  arms  still  when  stretched  out  horizontally, 
and  are  unable  to  exert  uniform  pressure  with  their  hands. 
In  a  still  higher  grade  patients  can  no  longer  dress  nor  feed 
themselves,  inasmuch  as  they  cannot  perform  such  simple  move- 
ments as  are  requisite  for  carrying  a  spoon  to  the  mouth,  but 
even  under  these  circumstances  they  may  be  able  to  exert  great 
muscular  power  in  resisting  passive  movements. 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  223 

The  ataxy  may  also  invade  the  muscles  of  the  trunk,  so  that 
the  body  makes  irregular,  swaying  movements,  owing  to  the 
impossibility  of  maintaining  the  due  balance  between  the 
various  muscles,  contraction  of  which  is  necessary  for  maintain- 
ino"  the  erect  posture.  The  muscles  of  the  neck  may  also  be 
implicated,  and  the  head  become  the  subject  of  irregular  and 
shaking  movements.  Speech  is  sometimes  also  interfered  with. 
At  first  the  ataxy  declares  itself  by  a  somewhat  indistinct  pro- 
nunciation of  words,  but  when  the  affection  is  more  advanced, 
there  is  an  irregular,  stuttering  interruption  of  speech.  At 
times  whole  sentences  are  uttered  rapidly,  and  then  there  is  a 
slight  stuttering,  and  this  is  repeated  in  an  irregular  manner; 
while  the  voluntary  movements  of  the  lips  and  tongue  are 
apparently  quite  unaffected.  In  the  highest  grades  of  the  affec- 
tion articulation  may  become  so  defective  that  speech  becomes 
almost  incomprehensible. 

The  third  and  final  stage  of  the  disease  is  characterised  by 
decided  paralysis,  although  a  certain  amount  of  motor  weakness 
may  be  shown  to  be  present  in  the  majority  of  cases  of  tabes 
even  at  a  moderately  early  stage  of  the  ataxic  period.  Partial 
and  temporary  paralysis  in  the  domain  of  single  nerves  in  the 
extremities  is  not  of  rare  occurrence.  In  the  later  stages  of  the 
disease  true  motor  paralysis  increases  and  ultimately  becomes 
the  predominant  symptom.  The  muscles  undergo  atrophy, 
or  contractures  set  in,  and  they  finally  become  more  or  less 
completely  paralysed.  With  the  appearance  of  the  paralysis 
the  ataxic  symptoms  are  thrown  more  and  more  in  the  back- 
ground. 

Symptoms  indicative  of  motor  irritation  are  not  prominent 
features  of  locomotor  ataxy.  In  the  earlier  stages  of  the  disease 
fibrillary  contractions  and  spasms  of  single  muscles,  with  slight 
jerking  of  a  limb,  may  be  observed.  At  times  twitchings  of 
entire  extremities  may  occur  in  connection  with  the  lancinating 
pains,  and  are  doubtless  reflex  in  nature. 

Muscular  tension  is  also  entirely  absent  from  true  cases  of 
tabes ;  the  limbs  are  limp  and  do  not  offer  the  least  resistance 
to  passive  movements.  When,  however,  the  paralytic  symptoms 
supervene  muscular  tension  and  contractures  also  arise,  and  may 
ultimately  reach  so  high  a  grade  that  the  limbs  remain  im- 


224  SYSTEM   DISEASES   OF  THE 

movable  in  the  position  of  extension  or  flexion  as  they  do  in 
the  later  stages  of  other  chronic  spinal  diseases. 

The  electrical  reactions  vary  at  different  stages  of  the  disease, 
and  the  statements  made  by  different  authors  with  regard 
to  them  are  not  in  accord  with  one  another.  Erb  found  the 
faradic  and  galvanic  excitability  to  be  quite  normal  in  respect 
both  to  quality  and  quantity.  In  another  series  of  cases  he 
found  a  slight  increase  in  the  faradic  and  galvanic  excitability 
in  the  anterior  muscles  of  the  leg,  without  any  qualitative 
alterations,  while  in  other  cases  he  found  a  more  or  less  distinct 
diminution  of  electrical  excitability  in  the  anterior  muscles  of 
the  leg,  without  qualitative  changes.  From  these  cases  Erb 
draws  the  general  conclusion  that  in  the  earlier  stages  of  the 
disease  there  is  an  increase  and  in  the  later  stages  a  diminution 
of  the  electric  contractility.  But,  as  Erb  confesses,  no  great 
advantage  is  to  be  gained  either  for  diagnosis  or  prognosis  from 
electrical  examinations. 

Reflex  Action. — The  cutaneous  reflex  is  usually  unaffected 
in  locomotor  ataxy,  at  least  until  a  late  period  of  the  disease. 
In  some  cases,  however,  the  normal  interval  between  the  cuta- 
neous excitation  and  the  resulting  contraction  may  be  greatly 
prolonged  (Fischer).  The  absence  of  the  reflex  action  of  the 
tendons  (§  78)  constitutes,  as  has  been  pointed  out  by 
Westphal,  one  of  the  most  remarkable  features  of  the  affection. 
The  patelJar-tendon  reflex  is  usually  absent  in  the  premonitory 
stage  of  the  disease,  and  often  long  before  the  ataxic  symptoms 
make  their  appearance,  and  it  is  consequently  one  of  the  most 
valuable  signs  of  the  disease  which  we  possess.  It  must,  how- 
ever, be  remembered  that  the  absence  of  the  patellar  reflex  is 
not  absolutely  pathogonomic  of  the  disease.  Erb  found  this 
reflex  absent  in  forty-eight  out  of  forty-nine  cases  examined  by 
him,  but  in  the  one  exception  the  reaction  was  very  lively.  I 
have  at  present  under  my  care  a  woman,  who  developed  symp- 
toms of  ataxia  somewhat  suddenly  two  years  ago  after  a  mis- 
carriage, and  in  whom  the  patellar-tendon  reflex  is  in  excess.  I 
have  seen  another  case,  which  will  be  subsequently  mentioned, 
where  symptoms  of  ataxia  were  associated  with  excessive  reaction 
of  the  patellar-tendon  reflex,  but  the  subsequent  course  of  the 
case  showed  that  it  was  one  of  insular  sclerosis.     I  thought  for 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  225 

some  time  that  the  case  of  the  woman  just  alluded  to  would 
turn  out  to  be  of  the  same  character;  but  after  watching  the  pro- 
gress of  her  case  now  for  eight  or  nine  months,  I  can  come  to  no 
other  conclusion  than  that  it  is  one  of  true  locomotor  ataxy.  The 
ataxic  gait  and  swaying  movements  on  closing  the  eyes  are 
well  marked  in  her,  it  is  true  that  she  has  not  suffered  much 
from  lancinating  pains,  but  there  is  decided  diminution  of 
tactile  sensibility  in  the  skin  over  the  external  aspect  of  both 
legs,  there  has  been  some  dribbling  of  urine,  and  there  is  com- 
plete absence  of  paralysis  and  muscular  tension.  But  not  only 
does  the  patellar-tendon  reflex  remain  unaffected  or  even  in 
excess  in  cases  of  true  tabes,  but  it  is  sometimes  absent  in  those 
who  are  otherwise  typically  healthy,  so  that  some  degree  of 
caution  is  necessary  in  accepting  the  absence  of  this  phenomenon 
as  a  sign  of  ataxia.  With  these  reservations,  however,  the 
absence  of  this  reflex  is  a  most  valuable  sign  of  locomotor 
ataxy. 

§  442.  Occasional  Symptoms. 

Paradoxical  Contraction.  —  Attention  has  recently  been 
drawn  by  Westphal  to  a  curious  phenomenon,  which  may  be 
regarded  as  the  opposite  of  the  tendon-reflex  contraction  of 
the  muscle.  As  this  symptom  was  unfortunately  overlooked  by 
me  when  the  first  volume  of  this  work  was  passing  through 
the  press,  I  shall  describe  it  in  detail  in  this  place: — 

It  consists  in  the  contraction  of  a  muscle  induced  by  suddenly  approxi- 
mating its  points  of  origin  and  insertion.  The  curious  circumstance  that 
a  sudden  relaxation  of  a  muscle  causes  it  under  certain  circumstances  to 
contract  has  led  Westphal  to  name  this  phenomenon  paradoxical  con- 
traction. This  symptom  is  best  studied  in  the  tibialis  anticus,  which 
may  in  certain  diseases  of  the  central  nervous  system  be  made  to  contract 
by  producing  sudden  or  sometimes  a  gradual  dorsal  flexion  of  the  foot. 
When  the  patient  is  laid  on  his  back  in  bed,  and  the  muscles  are  relaxed, 
especially  if  they  be  paralysed,  the  feet  occupy  the  position  of  extension 
or  plantar  flexion.  If  dorsal  flexion  of  one  foot  be  now  produced,  the 
tibialis  anticus,  under  certain  circumstances,  contracts,  its  tendon  becomes 
prominent,  and  the  foot  is  maintained  for  some  minutes,  sometimes  even 
as  long  as  twenty-seven  minutes,  in  the  position  of  dorsal  flexion  and 
adduction.  When  the  muscle  is  made  to  contract  by  direct  or  indirect  ex- 
citation or  by  voluntary  effort,  the  foot  may  remain  in  a  state  of  dorsal 
flexion  long  after  the  stimulus  has  ceased  to  act,  and  a  constant  current 
P 


226  SYSTEM  DISEASES   OF   THE 

passed  through  it  does  not  produce  relaxation.  Distinct  resistance  is  also 
offered  to  the  passive  production  of  plantar  flexion.  After  a  variable  length 
of  time  the  muscle  relaxes,  either  gradually  and  continuously,  or  with 
several  intermissions,  and  the  foot  falls  by  its  own  weight  to  the  position 
of  plantar  flexion.  The  paradoxical  contraction  sometimes  extends  to  the 
extensor  communis  digitorum  and  extensor  brevis  poUicis.  In  one  case 
observed  by  Westphal,  the  biceps  femoris  was  seen  to  contract  on  the  leg 
being  suddenly  flexed  on  the  thigh.  This  kind  of  contraction  may  be 
present  when  the  tendon  reflexes  are  absent  or  normal,  and  probably  also 
when  they  are  slightly  exaggerated ;  but  the  presence  of  distinct  ankle 
clonus  will,  of  course,  prevent  the  foot  from  becoming  fixed.  The  pheno- 
menon may  also  be  observed  when  the  cutaneous  sensibility  of  the  lower 
extremities  is  normal  or  lowered,  and  in  the  absence  of  any  excess  of  the 
cutaneous  reflex  excitability.  Paradoxical  contraction  is  generally  asso- 
ciated with  paresis  of  the  lower  extremities,  but  a  spastic  rigidity  of  the 
muscles  is  never  present,  although  a  slight  degree  of  resistance  may  be 
felt  to  passive  movements  of  the  leg  and  foot.  This  form  of  contraction 
may  extend  to  the  muscles  of  the  upper  extremities,  and  in  a  case 
observed  by  "Westphal,  in  which  some  of  them  were  affected,  a  certain 
amount  of  rigidity  subsequently  appeared  in  the  muscles  of  both  upper 
and  lower  extremities.  It  is  a  remarkable  circumstance  that  the  para- 
doxical contraction  occurs  in  muscles  like  the  tibialis  anticus,  which 
probably  never  contract  when  their  tendons  are  struck ;  and,  conversely, 
the  paradoxical  contraction  has  never  been  observed  in  muscles  like  the 
quadriceps  femoris,  which  manifest  readily  the  tendon-reflex  contraction. 
Whether  the  paradoxical  contraction  is  caused  by  reflex  or  direct  excitation 
is  not  known.  This  phenomenon  is  sometimes  a  symptom  of  locomotor 
ataxia,  but  probably  never  of  uncomplicated  cases  of  the  disease.  Its 
presence  may,  perhaps,  be  regarded  as  a  sign  that  the  lesion  in  the  pos- 
terior columns  is  extending  to  the  lateral  columns,  and  that  the  paralytic 
stage  of  the  disease  is  approaching.  This  contraction  has  also  been 
observed  by  Westphal  in  paralysis  agitans,  and  in  a  case  of  hsematomyeha 
at  present  under  my  care,  in  which  both  lower  extremities  are  completely 
paralysed,  paradoxical  contraction  is  readily  induced  in  the  tibialis  anticus 
of  the  right,  but  not  in  that  of  the  left  leg. 

Paralysis  of  the  Ocular  Muscles. — One  or  more  of  the 
ocular  muscles  are  not  unfrequently  paralysed  in  tabes  dorsalis, 
and  this  symptom  also  is  of  great  value  because  it  may 
precede  by  many  years  the  motor  inco-ordination  of  the  lower 
extremities.  The  motor  oculi  and  abducens  are  more  frequently 
affected  than  the  trochlear  nerve.  The  paralysis  of  the  ocular 
nerves  is  usually  transient,  and  generally  lasts  for  a  few 
days  or  months.  The  paralysis,  however,  often  recurs  after 
a  longer  or  shorter  time,  and  may  become  permanent  towards 


SPINAL   COED   AND  MEDULLA   OBLONGATA.  227 

the  later  stages  of  the  disease.  The  temporary  paralyses  of 
the  ocular  muscles  in  locomotor  ataxy  often  do  not  give  rise 
to  any  apparent  squint,  but  cause  double  vision  (diplopia), 
which  is  either  constantly  present,  or  only  when  the  eyes  are 
turned  in  particular  directions.  Distinct  squint  and  ptosis  are, 
however,  present  in  some  cases.  Out  of  64  cases  recorded  by 
Eulenburg,  25  had  strabismus;  of  these  25,  19  had  divergent 
strabismus,  and  4  had  in  addition  paralytic  ptosis,  while  6  had 
convergent  strabismus.  When  paralysis  of  the  third  or  sixth 
nerve  occurs  syphilis  is  generally  suspected  to  be  the  cause, 
and  if  the  paralysis  disappear  in  a  few  days  or  weeks  under 
treatment,  the  diagnosis  seems  to  be  placed  beyond  doubt. 
Paralysis  of  these  nerves  may,  however,  be  the  first  symptom 
of  locomotor  ataxy.  In  a  case  of  my  own,  paralysis  of  the 
sixth  nerve  appeared  to  have  been  promptly  cured  by  iodide  of 
potassium,  and  it  was  not  until  eighteen  months  afterwards 
that  the  ataxic  symptoms  declared  themselves  and  the  true 
nature  of  the  case  was  made  apparent. 

Mydriasis. — Dilatation  of  the  pupil  was  observed  by  Eulen- 
burg in  9  out  of  64  cases.  In  3  the  dilatation  was  double,  in 
4  single,  and  in  2  accompanied  by  myosis  of  the  other  eye. 
There  is  no  defect  of  accommodation  accompanying  this  con- 
dition ;  hence  it  would  seem  that  the  pupil  is  dilated  not  from 
paralysis  of  the  third  nerve,  but  from  irritation  of  the  cilio- 
spinal  nerves.  The  pupil  frequently  dilates  during  severe 
paroxysms  of  lancinating  pains  (Charcot)  and  during  gastralgic 
attacks  (Grainger  Stewart). 

Myosis. — Eulenburg  found  contraction  of  the  pupil  in  28  out 
of  64  cases,  21  showing  double  and  7  single  myosis.  The  two 
pupils  are  indeed  seldom  of  the  same  size,  and  the  degree  of 
contraction  varies  greatly  in  different  cases  and  in  the  same 
case  at  different  times.  Inequality  of  the  pupils  is  common  in 
the  early  stage  of  the  disease ;  and  on  the  side  on  which  the 
contraction  of  the  pupil  is  the  more  marked  there  may  be 
redness  of  the  cheek,  congestion  of  the  conjunctiva,  and  local 
elevation  of  temperature  (Charcot).  These  symptoms  indicate 
vaso-motor  paralysis,  and  prove  that  the  myosis  is  due  to 
paralysis  of  the  cilio-spinal  nerves. 

The  Argyll-Uobertson  Symptom. — This  symptom,  as  already 


228  SYSTEM  DISEASES   OF  THE 

mentioned  (§  225, 11),  consists  in  the  absence  of  any  contraction 
of  the  pupil  on  exposure  of  the  eye  to  light,  while  contraction 
with  the  accommodation  is  normally  retained.  The  symptom 
is  generally,  although  not  invariably,  associated  with  myosis. 

Nystiigmus  is,  as  Friedreich  has  shown,  occasionally  present 
in  locomotor  ataxy;  although,  contrary  to  what  occurs  in  multiple 
sclerosis,  it  is  an  exceedingly  rare  symptom.  The  nystagmus 
only  appears  when  attempts  are  made  to  fix  the  eye  on  an  object. 
The  movements  of  the  nystagmus  in  tabes  do  not  succeed  one 
another  with  the  same  rapidity  as  the  movements  in  ordinary 
nystagmus,  dependent  upon  disease  of  the  eye.  The  move- 
ments are,  indeed,  purely  ataxic,  and  only  occur  on  a  voluntary 
effort  at  fixation  being  made.  Ataxic  nystagmus  only  occurs 
in  certain  cases  which  possess  marked  clinical  peculiarities,  and 
it  is  always  a  late  symptom  of  the  disease. 

Atrophy  of  the  optic  nerve  is  a  frequent  and  distressing 
complication  of  locomotor  ataxy.  The  affection  begins  with 
slowly  or  rapidly  advancing  diminution  in  the  acuteness  of 
vision,  which  soon  terminates  in  amaurosis.  Colour  blind- 
ness can  usually  be  demonstrated  prior  to  any  limitation 
in  the  field  of  vision.  The  perception  of  green  is  first  lost, 
then  that  of  red,  yellow,  and  blue  in  succession,  although 
deviations  from  this  order  may  occasionally  occur  (Erb).  The 
pupils  are  usually  contracted  in  such  cases  and  they  do  not 
react  to  light.  The  blindness  is  caused  by  white  atrophy  of  the 
optic  nerve.  The  rapidity  with  which  blindness  supervenes 
is  very  variable.  At  times "  total  blindness  may  supervene 
in  a  few  weeks,  while  at  other  times  years  may  elapse  before 
the  loss  of  sight  is  complete,  and  occasionally  the  affection  may 
cease  to  progress  after  it  has  lasted  for  a  comparatively  long 
time.  The  disease  may  be  limited  to  one  eye,  but  usually  both 
eyes  are  simultaneously  attacked.  Atrophy  of.  the  optic  nerve 
appears  in  about  thirty  per  cent  of  all  cases  of  locomotor 
ataxy.  It  is  frequently  one  of  the  initial  symptoms  of  the 
disease,  and  sometimes  even  precedes  the  lancinating  pains. 
The  amaurosis  has  been  known  to  have  existed  ten  years  before 
the  other  symptoms  of  tabes  have  made  their  appearance. 

Disturbances  of  hearing  are  occasionally  observed  in  tabes. 
The  defect  of  hearing  is  sometimes  a  purely  accidental  circum- 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  229 

stance,  but  at  other  times  it  probably  depends  upon  atrophy 
of  the  auditory  nerve,  analogous  to  that  of  the  optic  nerve. 

Disturbances  of  taste  and  smell  have  also  occasionally  been 
observed,  but  are  of  subordinate  importance. 

The  trigeminus  at  times  manifests  signs  of  irritation,  givino- 
rise  to  pain  and  parsesthesiae,  or  it  may  be  either  partially  or 
completely  paralysed,  giving  rise  to  a  sense  of  numbness,  or  to 
anaesthesia.  Disturbances  of  taste  and  smell  are  always  asso- 
ciated with  an  abnormal  condition  of  the  trigeminus. 

The  facial  nerve  is  very  rarely  implicated,  but  irregular 
twitchings  of  the  facial  muscles  have  occasionally  been  observed. 
The  hypoglossal  nerve  has  been  rarely  affected.  The  pneumo- 
gastric  andglosso-pharyngeal  nerves  are  very  seldom  implicated, 
unless,  indeed,  the  gastralgic  troubles,  which  are  so  frequent 
and  distressing  in  tabes,  are  the  result  of  irritation  of  the 
pneumogastrics. 

Psychical  disturbances  are  but  seldom  observed.  Westphal 
has,  indeed,  shown  that  the  majority  of  patients  who  suffer  from 
progressive  paralysis  of  the  insane  appear  to  have  degeneration 
of  the  spinal  cord  chiefly  limited  to  the  posterior  columns.  The 
symptoms  of  progressive  paralysis  of  the  insane  may  precede 
the  tabes  for  many  years,  or  may  become  associated  with  it  after 
it  has  existed  for  many  years,  or  may  not  arise  until  the  terminal 
period  of  locomotor  ataxy.  In  all  these  cases  the  tabes  is  only 
one  of  the  manifestations  of  a  more  widely-diffused  degenerative 
process,  j  ust  as  ataxia  may  be  one  of  the  symptoms  of  multiple 
sclerosis. 

There  are  other  symptoms  of  locomotor  ataxy  which  do  not 
form  such  prominent  features  of  the  disease  as  those  already 
described,  but  are  not  on  that  account  less  remarkable  or  of 
less  importance.  These  are  what  may  be  denominated  visceral 
symptoms. 

Affections  of  the  Bladder  and  Rectum. — During  the  early 
stage  of  the  disease  the  patient  often  suffers  from  frequent  and 
painful  micturition,  along  with  neuralgic  pains  in  the  depth  of 
the  pelvis,  in  the  perinseum,  or  the  neck  of  the  bladder.  At 
a  later  stage  of  the  disease  signs  of  paresis  of  the  bladder  make 
their  appearance,  so  that  emptying  the  bladder  takes  a  longer 
time,  and  there  is  some  subsequent  dribbling,  or  there  maybe  a 


230  SYSTEM  DISEASES   OF  THE 

moderate  degree  of  incontinence ;  but  complete  paralysis  of  the 
bladder  is  exceedingly  rare,  and  only  occurs  in  the  last  stage  of 
the  disease.  A  certain  degree  of  vesical  catarrh  may  be  present 
during  the  terminal  stages  of  tabes,  but  it  is  seldom  of  a  severe 
character. 

Patients  also  complain  during  the  early  stage  of  tabes  of 
very  peculiar  sensations  in  the  rectum.  These  sensations  are 
at  times  described  by  the  patient  as  a  feeling  similar  to  that 
which  might  be  produced  by  the  forcible  introduction  into  the 
anus  and  rectum  of  a  long  and  voluminous  body  (Charcot). 
This  sensation  appears  suddenly  and  soon  disappears,  and  it  is 
usually  accompanied  by  a  strong  desire  to  evacuate  the  contents 
of  the  bowels,  and  occasionally  an  involuntary  evacuation  of 
fecal  matters  occurs.  At  a  more  advanced  period  of  the  disease 
anaesthesia  of  the  anus  may  be  present,  so  that  the  patients 
lose  the  feeling  of  approaching  evacuations,  and  hence  not 
unfrequently  dirty  themselves.  True  paralysis  of  the  sphincter 
is  rare  and  only  occurs  in  the  terminal  period  of  the  disease. 

Disturbances  of  the  Sexual  Functions. — A  certain  amount  of 
disturbance  of  the  genital  organs  is  rarely  absent  in  tabes.  In 
the  early  period  of  the  disease  symptoms  of  irritation  are  present. 
Trousseau  observed  in  certain  cases  a  singular  aptitude  for 
repeating  the  venereal  act  a  great  many  times  within  a  short 
period,  and  he  mentions  the  case  of  a  man  who  was  able  to 
have  connection  as  many  as  eight  or  nine  times  in  one  night. 
In  these  cases  the  appearance  of  excessive  virile  power  is  already 
conjoined  with  symptoms  indicative  of  weakness.  Very  often 
this  excessive  desire  has  been  preceded  by  a  certain  amount  of 
incontinence  of  urine  and  involuntary  seminal  emissions,  and 
the  erections  are  often  imperfect  and  accompanied  by  premature 
ejaculation.  Charcot  and  Bouchard  have  observed  symptoms  of 
genital  irritation  in  women.  As  the  ataxic  symptoms  manifest 
themselves  weakness  of  the  sexual  functions  set  in,  which  soon 
develop  into  complete  impotence,  although  some  tabetic  patients 
retain  their  sexual  power  undiminished  for  a  very  long  time. 

A  permanent  acceleration  of  the  pulse  has  been  mentioned 
amongst  the  symptoms  of  locomotor  ataxy.  The  temperature  of 
the  body  is  often  increased  during  the  attacks  of  lightning  pains. 

Gastralgic  attacks,  described  by  Charcot  under  the  name  of 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  231 

crises  gastriques,  are  frequently  observed  in  the  early  stage  of 
tabes.  I  know  a  gentleman  who  suffered  from  these  attacks, 
and  lancinating  pains,  ten  years  before  the  appearance  of  the 
ataxic  symptoms.  The  gastralgic  attack  generally  begins  sud- 
denly during  a  paroxysm  of  the  lancinating  pains.  The  patient 
complains  of  pain,  which  starts  from  the  groins  and  appears  to 
pass  up  each  side  of  the  abdomen,  so  as  to  become  fixed  in  the 
epigastric  region.  At  the  same  time  severe  pains  are  felt 
situated  between  the  shoulders,  which  radiate  round  the  base  of 
the  thorax,  under  the  form  of  lightning  pains.  As  a  rule,  the 
action  of  the  heart  is  violent,  and  accelerated  during  the  attacks, 
which  are  generally  accompanied  by  extremely  painful  and  in- 
cessant vomiting.  The  food  is  rejected,  then  a  quantity  of 
watery  mucus,  which  is  at  first  colourless,  but  may  ultimately 
become  mixed  with  bile  and  blood.  A  profound  malaise  and 
vertigo  are  conjoined  with  the  vomiting,  while  the  lightning 
pains  are  unusually  severe,  so  that  the  sufferings  of  the  patient 
may  become  truly  agonising.  These  attacks  may  last  without 
respite  for  two  or  three  days,  and  may  recur  every  two  weeks  ; 
but  usually  the  interval  between  the  attacks  is  not  less  than  a 
month.  During  the  interval  the  functions  of  the  stomach  are 
entirely  unaffected.  The  gastralgic  attacks  may  begin  at  an 
early  stage  of  the  disease,  and  may  constitute  for  many  years, 
along  with  the  lightning  pains,  the  only  symptom  of  the 
approaching  malady.  These  attacks  do  not,  however,  always 
disappear  on  the  ataxic  symptoms  being  established,  but  may 
continue  to  recur  until  the  fatal  termination  of  the  disease. 

Nephralgic  attacks  have  recently  been  described  by  Raynaud 
which  present  symptoms  almost  entirely  similar  to  renal  colic, 
only  that  there  is  entire  absence  of  calculi,  gravel,  or  blood 
from  the  urine. 

Bronchial  attacks  have  been  described  by  F^reol  under  the 
name  of  "  bronchial  crises,"  consisting  of  paroxysms  of  spas- 
modic cough,  difficulty  of  breathing  and  swallowing.  In  cases 
described  by  Friedreich  vertigo  has  been  a  very  prominent 
symptom. 

Va.so-motor  Disturbances. — Vaso-motor  disturbances  are  not 
prominent  features  of  locomotor  ataxy.  Patients  not  unfre- 
quently  complain  of  cold  feet ;   and  sometimes  there  is  a  great 


232  SYSTEM  DISEASES   OF  THE 

tendency  to  the  formation  of  cutis  anserina.  The  skin  is  at 
times  mottled,  and  there  may  be  increased  or  diminished  cuta- 
neous secretion.  A  curious  case  has  recently  been  described  by 
E.  Remak,  in  which  the  ataxic  symptoms  began  iu  the  right 
upper  extremity.  The  muscles  of  the  forearm  were  somewhat 
wasted,  but  there  was  no  distinct  loss  of  motor  power,  yet  the 
hand  was  rendered  practically  useless  from  the  disorderly  move- 
ments which  occurred  when  any  attempt  was  made  to  use  it. 
Serious  sensory  disturbances  were  observed  in  the  extremity 
affected  with  ataxia,  and  slight  analgesia  of  the  sole  of  the  right 
foot.  There  were  also  slight  swaying  movements  on  closing  the 
eyes,  and  the  patellar-tendon  reflexes  were  absent,  but  there 
were  no  lancinating  pains  and  no  ataxic  or  paralytic  symptoms 
in  the  lower  extremities.  In  addition  to  these  symptoms,  the 
patient  suffered  from  unilateral  hyperidrosis  limited  to  the  right 
side,  redness  and  slight  relative  increase  of  temperature  of  the 
right  half  of  the  face  and  side  of  the  head,  and  myosis  of  the 
right  pupil,  the  latter  becoming  more  marked  with  the  increase 
of  the  secretion  of  sweat,  and  frequently  disappearing  altogether 
with  complete  rest.  The  secretion  of  sweat  was  increased  on  the 
right  side  when  the  patient  took  any  acid  substance  into  his 
mouth,  and  also  by  faradic  excitation  of  the  tongue  and  mucous 
membrane  of  the  mouth,  or  of  the  skin  of  the  cheek,  and  trunk 
of  the  facial  nerve.  The  conjunctiva  is  said  by  Trousseau  to  be 
frequently  congested  in  locomotor  ataxia. 

Trophic  Disturbances. — The  most  common  trophic  affections 
are  eruptions  of  the  skin,  such  as  herpes,  lichen,  or  the  forma- 
tion of  bullae,  like  those  of  pemphigus.  Bed-sores  usually 
belong  to  the  terminal  period  of  the  disease  only.  Dr.  Buzzard 
reports  a  case  of  locomotor  ataxy,  in  which  an  eruption  of  herpes 
occurred  in  the  right  gluteal  region  during  every  paroxysm  of 
lightning  pain.  The  patient  stated  that  he  must  have  suffered 
from  fifty  or  sixty  attacks  of  herpes  during  the  four  years  pre- 
vious to  the  report  of  his  case.  The  nutrition  of  the  muscles 
remain  for  a  long  time  unaffected;  and,  indeed,  the  muscles  of 
the  lower  extremities  may  undergo  a  certain  amount  of  hyper- 
trophy during  the  early  part  of  the  ataxic  stage,  owing  to  the 
excessive  activity  to  which  they  are  subjected.  Daring  the 
paralytic  stage  the  muscles  may  waste  rapidly,  simply  from 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  233 

disuse,  and  not  from  any  active  atrophy.  Occasionally,  how- 
ever, the  disease  becomes  complicated  at  a  comparatively  early 
period  with  atrophy  of  certain  muscles,  such  as  those  of  the 
calves  of  the  legs,  or  those  of  the  thighs,  ball  of  the  thumb,  or 
of  one-half  of  the  tongue;  and  in  these  cases  the  atrophy  con- 
sists of  active  degeneration,  and  not  merely  of  the  passive 
degeneration  which  is  caused  by  functional  inactivity.  The 
most  remarkable  trophic  disturbances  which  occur  in  tabes  are 
the  affections  of  the  joints,  which  have  been  described  by 
Charcot  under  the  name  of  arthropathies  des  ataxiques.  It  is 
possible  to  meet  with  joints  deformed  with  rheumatic  gout,  and 
dry  arthritis  coincidently  with  tabes,  but  the  arthropathies  of 
locomotor  ataxia  develop  themselves  quite  independently  of  any 
general  affection.  This  affection  always  appears  during  the 
early  stage  of  tabes,  usually  during  the  stage  of  the  lightning 
pains,  although  many  cases  seem  to  contradict  this  rule.  The 
joints  of  the  upper  extremities  may,  for  instance,  become  affected 
at  an  advanced  period  of  the  disease.  The  disease  has,  however, 
only  reached  an  advanced  stage  in  the  lower  extremities;  while 
the  upper  extremities  are  only  just  beginning  to  manifest  the 
initial  stage  of  the  affection.  The  joint  most  frequently  affected 
is  the  knee-joint;  and  then  in  a  descending  order  of  frequency, 
the  shoulder,  elbow,  the  hip-joint,  and  the  wrist  in  succession. 

Various  luxations  of  the  joints  ensue,  producing  notable 
deformities. 

In  locomotor  ataxy  the  bones  also  sometimes  become  abnor- 
mally friable,  so  that  spontaneous  fractures  may  occur,  a  change 
which  is  no  doubt  of  similar  origin  to  the  joint  affection. 

The  following  case,  reported  by  Dr.  Dreschfeld,  will  illustrate 
the  arthropathies  of  locomotor  ataxy: — 

B.  W ,  aged  fifty,  mechanic,  married,  with  no  history  of  either 

syphilis  or  alcoholism,  had  always  enjoyed  good  health  till  fifteen  years 
ago,  when  the  first  symptoms  of  locomotor  ataxy  came  on.  These  symp- 
toms consisted  in  the  inability  to  walk  in  the  dark,  and  in  the  presence  of 
lightning-like  pains  in  the  legs,  in  consequence  of  which  he  was  soon 
obliged  to  give  up  his  work.  Seven  years  ago  the  pains  in  the  right  thigh, 
without  losing  their  lightning-like  character,  became  suddenly  much  more 
persistent,  and  obliged  the  patient  to  take  to  his  bed,  and  to  remain  in  bed 
for  a  month,  when  they  left  him  as  suddenly  as  they  came.  On  trying  to 
get  up  he  found  now  that  his  right  leg  was  much  shorter  than  the  left, 


234  SYSTEM  DISEASES   OF  THE 

and  that  there  was  a  projection  on  the  right  hip,  which  occasionally  would 
suddenly  disappear  with  a  peculiar  noise.  Any  movement  of  the  thigh  or 
leg  would,  however,  make  this  projection  very  soon  reappear.  Three  years 
ago  the  left  knee  began  to  give  way  without  any  exacerbation  of  pain,  or 
any  sudden  swelUng  of  the  joiut,  and  very  gradually  assumed  its  present 
position,  that  of  extreme  backward  dislocation.  In  consequence  of  these 
joint  affections,  walking,  which  was  already  difficult  before,  became 
only  possible  with  the  help  of  two  sticks.  The  general  health  of  the 
patient  had  remained  very  good  throughout,  his  eyesight  had  been  bad 
for  some  years,  but  he  had  never  suffered  from  vomiting  or  any  bladder 
troubles. 

On  admission  patient  looked  well  and  healthy  ;  the  thighs  were  con- 
siderably wasted,  but  the  rest  of  the  body  was  not  emaciated.  The  chest 
and  abdominal  organs  were  perfectly  healthy.  There  was  no  affection  of 
any  of  the  cerebral  nerves,  except  marked  white  atrophy  of  both  of  the 
discs.  The  pupils  were  contracted  and  reacted  to  accommodation,  but 
not  to  light.  The  upper  extremities  were  perfectly  normal.  The  lower 
extremities  showed  the  chief  symptoms,  and  here,  as  regards  (1)  sensation, 
there  were  diminution  of  tactile  sensibility,  analgesia  of  certain  spots, 
and  retardation  of  sensibility.  The  sense  for  temperature  and  weight  was 
normal ;  the  muscular  sense  was  considerably  affected.  The  patellar-ten- 
don  reflex  was  quite  absent.  Both  lower  extremities  were  often  the  seat 
of  the  lightning  pains.  As  regards  (2)  trophic  changes,  (a)  the  muscles 
of  both  thighs  were  flabby  and  atrophied,  but  especially  the  muscles  of  the 
left  thigh.  (6)  There  was  marked  dislocation  backwards  of  the  left  thigh, 
so  that  when  the  patient  stood  the  upper  surface  of  the  tibia  could 
distinctly  be  felt  under  the  skin.  There  was  no  atrophy  of  either  of  the 
articulating  surfaces,  nor  any  new  deposit  of  bone  round  the  joint  as  far 
as  could  be  made  out  on  manual  examination.  The  head  of  the  right 
femur  was  dislocated  on  to  the  dorsum  of  the  ilium,  and  could  be  felt  as  a 
distinct  round  projection  ;  it  was  freely  movable  and  could  easily  be 
reduced,  but  very  soon  slipped  out  again  from  the  acetabulum  on  to  the 
dorsum.  Owing  to  this  dislocation  the  left  knee  was  situated  four  inches 
lower  than  the  right  knee,  which  difference  disappeared  as  soon  as  the 
reduction  of  the  head  of  the  femur  was  effected  (Plate  IV.  1,  2).  The  head 
of  the  dislocated  femur  did  not  seem  to  be  atrophied,  nor  were  there  any 
bone  deposits  to  be  felt  about  the  joint  cavity.  A  mass  of  bone,  however, 
of  more  than  one  inch  in  length  was  felt,  situated  in  the  sheath  of  the 
sartorius  muscle,  totally  unconnected  with  the  joint,  but  moving  freely 
with  the  muscles  during  this  contraction.  As  regards  (3)  motility,  there 
was  considerable  diminution  of  motor  power  in  both  legs,  but  more  in  the 
right  than  in  the  left ;  the  patient  was,  however,  able  to  stand  and  to  walk 
with  the  help  of  two  sticks ;  his  walk  was  characteristically  ataxic ;  he 
was  unable  to  walk  with  his  eyes  shut,  and  with  his  eyes  open  his  gait 
was  very  unsteady,  owing  to  the  ataxy  and  the  dislocations. 


Piatt:  iv 


^■^^ 


r- V 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  235 

§  443.  Varieties. — The  largest  number  of  cases  of  locomotor 
ataxy  follow  a  very  uniform  course,  which  may  therefore  be 
regarded  as  forming  the  type  of  the  disease.  The  symptoms, 
however,  may  deviate  considerably  from  their  usual  course,  or 
the  affection  may  be  observed  in  combination  with  other  allied 
forms  of  disease.  Locomotor  ataxia  may,  therefore,  be  divided 
into  the  following  varieties  (Erb) : — 

(1)  The  Regular  Typical  Form  of  Tabes. — It  usually  attacks  men  during 
middle  age.  It  begins  with  lancinating  pains,  disturbances  of  the  nerves 
supplying  the  ocular  muscles  and  of  the  optic  nerves,  disturbances  of  sen- 
sibility of  the  extremities,  such  as  pareesthesia,  slight  anaesthesia,  feeling 
of  a  tight  girdle,  great  feeling  of  fatigue,  motor  disturbances  in  the  lower 
extremities,  such  as  swaying  on  closing  the  eyes,  and  disturbances  of  the 
urinary  and  genital  organs. 

During  the  second  stage  of  the  disease  the  symptoms  of  the  first  stage 
gradually  increase,  and  now  become  associated  with  characteristic  ataxia. 
Patients  become  more  and  more  helpless,  there  are  well  marked  distur- 
bances of  sensibility,  such  as  partial  anaesthesia,  retardation  of  the  per- 
ception of  pain,  abolition  of  tendon-reflex  along  with  increase  of  vesical 
and  sexual  weakness. 

In  the  third  or  terminal  stage  true  paralysis  gradually  supervenes  in  the 
form  of  paraplegia ;  there  are  also  contractures,  muscular  atrophy,  bed- 
sores, and  progressive  cachexia. 

(2)  Tlie  Form  of  Tabes  described  by  Friedreich. — Family  predisposition 
forms  a  prominent  feature  of  the  disease,  and  the  female  members  of  these 
families  manifest  a  tendency  to  be  attacked  by  preference.  The  disease 
generally  begins  between  the  age  of  twelve  and  eighteen  years.  Lanci- 
nating pains  are  rare  at  the  beginning,  but,  on  the  other  hand,  the  ataxia 
begins  early,  and  rapidly  spreads  from  the  lower  to  the  upper  extremities, 
and  sometimes  even  arises  simultaneously  in  the  upper  and  lower  extremi- 
ties. Co-ordinating  disturbances  of  speech  and  ataxic  nystagmus  are 
generally  present.  Disturbances  of  sensibility  are  absent  or  insignificant ; 
the  sensibility  of  the  skin  and  muscles  remains  unaffected  for  many 
years.  No  swaying  on  closure  of  the  eyes.  Tendon-reflex  abolished.  No 
disturbances  of  the  bladder  or  bed-sores,  and  no  psychical  disturbances, 
tremor,  or  amaurosis.  Muscular  atrophy,  paresis,  contractures,  weakness 
of  the  bladder  appear  only  in  the  last  stage.  The  affection  is  usually  of 
remarkably  long  duration,  extending  sometimes  over  thirty-two  years. 

(3)  Anomalous  Forms. — Sometimes  the  degenerative  changes  do  not 
remain  limited  to  the  posterior  columns,  but  extend  to  other  segments  of 
the  cord,  giving  rise  to  a  combination  of  the  symptoms  of  locomotor 
ataxy  with  those  of  one  or  more  of  the  other  systematic  diseases  of  the 
cord. 


23G  SYSTEM   DISEASES   OF  THE 

(4)  Paraplegic  Form. — In  a  certain  number  of  cases  manifestations  of 
motor  weakness  come  into  prominence  at  an  early  period  of  the  disease, 
so  that  the  tabetic  symptoms  become  obscured.  The  symptoms  may  in 
such  cases  suggest  paraplegia,  and  emaciation  and  atrophy  of  the  legs 
may  seem  to  confirm  this  opinion.  In  these  cases  the  degenerative 
changes  have  no  doubt  extended  to  the  pyramidal  fibres  of  the  lateral 
columns  and  to  the  anterior  horns  of  the  grey  substance. 

(5)  Neuralgic  Form. — In  other  cases  the  lancinating  pains  constitute 
the  most  prominent,  and  for  a  long  time,  sometimes  upwards  of  twenty 
years,  the  only  symptoms  of  the  disease.  This  form  has  been  called  "tabes 
dolorosa." 

(6)  Meningitic  Form. — At  times  locomotor  ataxy  becomes  complicated 
with  spinal  meningitis,  and  such  cases  may  offer  a  very  variable  combina- 
tion of  symptoms.  Circumscribed  or  diffused  cutaneous  hyperaesthesia, 
pain  in  the  back,  and  spinal  tenderness  are  some  of  the  symptoms  which  are 
most  commonly  present.  Locomotor  ataxy  may  also  be  complicated  with 
various  psychical  disturbances,  and  these  must  be  subjected  to  a  special 
investigation. 

§  444.  Course,  Duration,  and  Termination.  —  The  usual 
development  of  the  locomotor  ataxia  is  slow  and  chronic,  ex- 
tending over  months  or  years,  although  cases  have  been 
described  under  the  name  of  acute  ataxia  which  run  a  rapid 
course.  As  a  rule,  single  symptoms  arise  which  remain  isolated 
for  a  long  time,  and  with  which  others  become  after  a  time 
associated  until  in  the  course  of  months  or  years  the  picture  of 
the  disease  is  complete.  The  ataxic  symptoms,  as  already  men- 
tioned, usually  begin  in  the  lower  extremities,  but  a  few  cases 
are  reported  in  which  the  upper  extremities  were  first  affected. 
Occasionally  a  unilateral  development  has  been  observed. 

When  the  disease  is  fully  developed  the  intensity  of  the 
symptoms  progressively  increases,  new  symptoms  arise,  and  the 
condition  of  the  patient  gradually  grows  worse.  The  disease 
may,  however,  remain  stationary,  or  even  undergo  a  marked 
improvement  for  months  or  years;  but  after  a  time  an  un- 
favourable change  usually  takes  place.  The  patients  feel  better 
in  summer  and  worse  in  winter,  but  they  generally  lose  more 
in  cold  than  they  gain  in  warm  weather.  In  rare  cases  the 
improvement  may  progress  to  complete  recovery.  The  duration 
of  the  disease  is  always  to  be  counted  by  years,  and  sometimes 
by  decades.    Even  the  initial  stage,  with  lancinating  pains,  may 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  237 

last  over  twenty  years.  In  the  majority  of  typical  cases  of  the 
disease  the  average  duration  of  life  appears  to  be  from  eight  to 
twelve  years,  and  in  these  cases  death  is  caused  by  bed-sores, 
cystitis,  or  bulbar  symptoms,  or  the  spinal  affection  renders  the 
patient  less  capable  of  surviving  intercurrent  attacks  of  disease, 
such  as  pneumonia,  the  exanthemata,  or  other  fevers. 

Recovery  is  not  unusual  in  the  initial  stage  under  appro- 
priate treatment;  and  even  when  the  disease  is  fully  developed, 
recovery,  or  an  improvement  bordering  on  recovery,  may  take 
place.  Often,  however,  patients  must  be  content  with  a 
moderate  improvement,  or  an  arrest  of  the  malady.  As  a  rule, 
the  disease  is  of  a  progressive  character,  and  the  most  judicious 
treatment  may  fail  to  bring  about  even  a  temporary  improve- 
ment. A  fatal  termination  may  be  brought  about  in  various 
ways.  The  disease  may  lead  to  paraplegia,  cystitis,  and  bed- 
sores, and  the  patient  dies  from  the  usual  symptoms  of  severe 
spinal  paralysis.  During  the  last  few  days  cerebral  symptoms, 
as  coma  and  delirium,  may  supervene.  The  morbid  process 
may,  in  progressing  from  below  upwards,  involve  the  medulla 
oblongata,  and  cause  death  by  interfering  with  respiration  or 
with  the  act  of  deglutition.  Very  frequently  some  intercurrent 
affection,  such  as  typhus,  pneumonia,  diphtheria,  and  phthisis, 
causes  a  fatal  termination. 

§  445.  Morbid  Anatomy. — The  spinal  pia  mater  is  often 
thickened,  cloudy,  and  connected  by  numerous  adhesions  to  the 
dura  mater.  The  change  in  the  pia  mater  is  generally  confined 
to  the  posterior  aspect  of  the  cord,  being  circumscribed  by  the 
posterior  roots  on  each  side.  Occasionally,  however,  the  pia 
mater  appears  altered  over  a  larger  area,  and  the  spinal  fluid 
is  almost  always  increased  in  quantity.  The  spinal  cord  is 
generally  altered  in  form,  being  flattened  from  before  back- 
wards over  a  considerable  portion  of  its  extent,  caused  by  a 
diminution  of  the  volume  of  the  posterior  column.  On  making 
transverse  sections  at  different  levels  of  the  cord,  a  grey  or 
greyish-yellow  discolouration  may  be  observed  along  the  pos- 
terior median  fissure,  extending  almost  the  entire  length  of  the 
cord.  The  consistence  of  the  cord  is  usually  increased,  but 
occasionally  it  may  be  diminished. 


238  SYSTEM   DISEASES  OF  THE 

The  posterior  roots  are  discoloured,  grey,  translucent,  and 
atrophied,  this  condition  being  particularly  well  marked  in 
the  Cauda  equina.  Dr.  Carter,  of  Liverpool,  exhibited  the 
spinal  cord  from  a  case  of  locomotor  ataxy  at  a  recent  medical 
meeting  in  Manchester,  in  which  the  ganglia  of  the  posterior 
roots  of  the  sacral  and  lumbar  nerves  were  greatly  enlarged. 

The  degeneration  is  not,  as  a  rule,  uniformly  distributed  over 
the  whole  transverse  section  of  the  posterior  columns.  The 
columns  of  Goll  are  usually  affected  over  their  entire  length, 
and  the  posterior  root-zones  are  always  affected  to  a  more  or 
less  extent,  although  they  are  not  often  degenerated  throughout 
the  entire  length  of  the  cord.  In  the  inferior  portion  of 
lumbar  enlargement  there  is  frequently  only  a  slight  grey 
discolouration  in  the  external  half  of  the  posterior  columns ; 
but  on  ascending  it  increases  in  width,  so  that  in  the  upper 
half  of  the  lumbar  enlargement  the  discolouration  embraces 
the  entire  transverse  section  of  the  posterior  columns.  The 
whole  of  the  posterior  columns  are  usually  affected  throughout 
the  entire  length  of  the  dorsal  region,  but  its  extent  diminishes 
again  in  the  cervical  portion,  and  the  degeneration  becomes 
limited  in  the  upper  cervical  region  to  the  columns  of  Goll. 
As  a  rule,  the  intensity  and  extent  of  the  morbid  process  is 
greatest  in  the  upper  lumbar  and  the  dorsal  portions,  dimi- 
nishing both  upwards  and  downwards  from  these  points. 

The  morbid  changes  may  extend  upwards  into  the  me- 
dulla oblongata,  along  the  ascending  root  of  the  trigeminus 
(Pierret).  The  posterior  horns  of  grey  matter  often  appear  of 
a  dark  grey  colour,  shrivelled,  and  distorted,  and  the  vesicular 
columns  of  Clarke  have  been  found  altered.  The  discolouration 
may  also  extend  forwards  from  the  posterior  horns  to  the  direct 
cerebellar  fibres  and  the  pyramidal  fibres  of  the  lateral  column. 
Such,  then,  are  the  morbid  appearances  which  are  found  in 
fully-developed  cases  of  the  disease,  but  in  cases  which  have 
died  from  an  intercurrent  affection  during  the  early  stages  of 
locomotor  ataxia  the  morbid  appearances  met  with  are  some- 
what different.  Charcot  and  Pierret  have  shown  that,  although 
the  columns  of  Goll  are  usually  implicated  in  locomotor  ataxy, 
the  ataxic  symptoms  may  be  present  in  a  high  degree  in 
the  entire  absence  of  any  affection  of  these  columns.    Sclerosis 


SPINAL   CORD   AND   MEDULLA   OBLONGATA. 


239 


of  the  posterior  root-zones  is,  according  to  these  authors,  the 
essential  morbid  alteration  of  locomotor  ataxia,  and  even  the 
whole  width  of  these  zones  need  not  be  implicated.  A  certain 
amount  of  alteration  of  these  zones  may  be  detected  by  micro- 
scopic examination,  if  not  by  the  naked  eye,  even  in  those  cases 
that  have  died  by  an  intercurrent  disease  during  the  stage  of 
the  lancinating  pains  before  the  ataxic  symptoms  had  made 
their  appearance.  And  on  the  other  hand,  in  a  woman  in  whom 


Fig.  ]76. 


Fia.  176  (Charcot  and  Pierret).  Transverse  Section  of  the  lower  portion  of  the 
Lumbar  Enlargement,  from  a  case  of  Locomotor  Ataxia. — A,  Posterior  roots ; 
B,  Internal  radicular  fasciculus,  the  sclerosis  being  limited  to  its  course ;  C', 
Eight  anterior  grey  horn  in  a  state  of  atrophy. 

the  disease  appeared  in  a  generalised  form,  the  superior,  as  well 
as  the  inferior,  extremities  being  the  subject  of  the  lightning 
pains  and  motor  inco-ordination,  the  posterior  root-zones  were 
found  affected  the  whole  length  of  the  cord,  while  there 
was  complete  absence  of  any  affection  of  the  columns  of  Goll 
{Fig.  176,  B). 

In  very  old  and  protracted  cases  long  portions  of  the  spinal 
cord  appear  hardened  and  atrophied  in  its  entire  thickness. 
On  making  a  transverse  section,  the  whole  is  found  transformed 
into  a  grey  translucent  mass,  in  which  it  is  difficult  to  recognise 
even  the  distinction  between  grey  and  white  matter. 

The  microscopical  changes  in  the  cord  consist  in  the  early  stage 
of  thickening  of  the  interstitial  tissue,  increase  in  the  number 


240  SYSTEM  DISEASES   OF  THE 

of  nuclei  along  with  the  formation  of  enlarged  and  highly- 
developed  Deiter's  cells. 

The  nerve  fibres  dwindle  gradually  and  ultimately  disappear. 
The  medullary  sheath  does  not  usually  undergo  fatty  degenera- 
tion or  break  down,  and  no  swelling  of  the  axis  cylinder  is 
observed ;  there  is  simple  atrophy  and  disappearance  of  the 
nerve  fibres,  and  numerous  granule  cells  are  found.  In  recent 
cases  the  vessels  are  generally  thickened,  the  nuclei  are  increased 
in  number,  and  corpora  amylacea  are  scattered  throughout  the 
tissue  in  greater  or  lesser  number.  In  the  later  stages  the  prin- 
cipal mass  of  the  structure  is  composed  of  a  firm  fibrillar,  often 
wavy,  connective  tissue,  which  contains  numerous  nuclei  and  is 
disseminated  with  innumerable  corpora  amylacea.  Most  of  the 
nerve  fibres  have  disappeared,  but  even  in  advanced  cases  some 
well-preserved  but  isolated  fibres  may  still  be  seen  scattered 
through  the  firm  connective  tissue. 

The  posterior  roots,  in  their  passage  through  the  posterior 
root-zones  to  the  posterior  grey  horns — the  inner  radicular 
fasciculus — are  involved  in  the  degenerative  process.  Their 
fibres  are  broken  down  and  atrophied,  some  are  completely 
destroyed,  while  the  remains  of  those  left  are  separated  from 
one  another  by  broad  bands  of  connective  tissue. 

The  posterior  horns  of  grey  matter  are  also  implicated  in 
the  degeneration.  There  is  thickening  of  the  connective  tissue, 
disappearance  of  nerve  fibres,  and  the  ganglion  cells  are  pig- 
mented but  not  much  changed  in  other  respects.  Clarke's 
columns  are  also  frequently  implicated,  although  their  ganglion 
cells  remain  tolerably  intact. 

Sometimes  the  degenerative  process  extends  to  the  anterior 
horns  of  grey  matter,  injuring  the  large  ganglion  cells,  and 
then  the  muscles  innervated  from  the  diseased  grey  matter  are 
always  in  a  state  of  atrophy.  This  alteration  stands,  according 
to  Pierret,  in  connection  with  sclerosis  of  the  inner  radicular 
fasciculus,  and  extends  from  those  along  the  bundles  of  fibres 
that  radiate  into  the  anterior  grey  horns.  In  the  annexed  diagram 
the  ganglion  cells  of  the  right  anterior  horn  {Fig.  177,  D)  are 
in  great  part  destroyed,  and  the  muscles  of  the  upper  and  lower 
extremities  of  the  same  side  were  atrophied. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA. 


241 


Most  recent  observers  are  of  opinion  that  the  degenerative 
process  begins  within  the  cord  itself,  and  not  in  the  posterior 
roots.  Leyden  thinks  that  the  process  from  beginning  to  end 
consists  of  a  degeneration;  while  Charcot,  Friedreich,  and  others 
look  upon  the  degenerative  changes  as  the  result  of  chronic 
inflammation.  All,  however,  are  agreed  that  the  process 
begins  in  the  nerve  elements  themselves,  and  extends  from 
them  to  the  interstitial  tissue.  The  disease  may,  however, 
begin  at  times  in  the  pia  mater,  and  spread  thence  to  the 
posterior  root-zones  and  columns  of  Goll. 

Fjg.  177. 


Fig.  177  (Charcot  and  Pierret).  Transverse  Section  of  the  Lumbar  Region,  from  a 
case  of  Locomotor  Ataxia,  complicated  with  Muscular  Atrophy. — A,  A,  Sclerosis 
of  the  posterior  root-zone ;  C,  Left  anterior  grey  horn,  healthy ;  D,  Right 
anterior  grey  horn  in  a  state  of  atrophy. 

The  posterior  nerve  roots  are  atrophied  in  the  late  stages  of 
the  disease.  They  appear  as  flat,  grey,  translucent  bands,  and 
exhibit  degenerative  atrophy  of  the  nerve  fibres  and  prolifera- 
tion of  connective  tissue. 

The  peripheral  nerves,  the  anterior  nerve  roots,  the  sympa- 


242  SYSTEM  DISEASES  OF  THE 

thetic  system,  and  the  muscles  are  generally  quite  normal.  The 
spinal  ganglia  of  the  posterior  roots  have,  however,  been  found 
diseased  (Carter).  Some  of  the  cranial  nerves  have  also  been 
found  diseased,  grey  degeneration  of  the  optic  nerves  being  the 
most  frequent  change  observed.  Morbid  changes  have  been 
found  on  rare  occasions  in  the  oculo-motorius,  abducens,  and 
hypoglossus.  The  nuclei  of  these  nerves,  on  the  floor  of  the 
fourth  ventricle,  also  appear  sometimes  to  be  affected. 

When  arthropathies  form  a  part  of  the  disease  there  is 
disappearance  of  the  articular  cartilages,  and  the  articular  ends 
of  some  of  the  bones  are  eroded.  There  is  little  or  no  tendency 
to  exostosis.  In  more  recent  cases  the  amount  of  articular  fluid 
is  greatly  increased,  points  of  thickening  and  fungosities  are 
found  on  the  synovial  membrane,  the  surrounding  soft  parts 
are  swelled  and  suffused  with  fluid. 

The  changes  in  the  skin  and  viscera  are  the  same  as  in 
chronic  myelitis. 

§  446.  Morbid  Physiology. — The  general  opinion  amongst 
pathologists  at  present  is  that  sclerosis  of  the  posterior  root-zones 
of  the  spinal  cord  for  a  considerable  portion  of  their  longitudinal 
extent  is  the  essential  morbid  alteration  in  locomotor  ataxia. 
As  the  disease  extends  horizontally  towards  the  posterior  median 
fissure,  the  columns  of  GoU  become  implicated,  and  when  once 
the  fibres  of  these  columns  become  interrupted  in  any  part  of 
their  course  the  portions  above  the  seat  of  lesion  undergo 
degeneration,  so  that  sclerosis  of  the  columns  of  Goll  through- 
out their  entire  length  is  usually  present,  although  it  does  not 
appear  to  constitute  a  necessary  part  of  the  morbid  change.  As 
the  sclerosis  spreads  outwards,  the  inner  radicular  fasciculus 
and  posterior  grey  horns  become  occasionally  affected;  and  in 
many  cases,  as  already  remarked,  the  disease  extends  to  the 
anterior  grey  horns  and  lateral  columns. 

The  lancinating  pains  may  be  explained  by  irritation  of  the 
posterior  nerve  roots,  and  their  prolongations  through  the  pos- 
terior columns,  while  the  subsequent  anaesthesia  is  caused  by 
destruction  of  the  posterior  root  fibres.  The  absence  of  the 
patellar-tendon  reflex  is  caused  by  disease  of  the  afferent 
portion  of  the  reflex  arc  in  its  passage  through  the  posterior 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  243 

columns.  It  is  probable  that  irritation  of  these  fibres  may  in 
the  early  stage  of  this  disease  give  rise  to  excess  of  the  tendon 
reflex. 

Retardation  of  painful  impressions  and  analgesia  are  caused 
by  disease  of  the  grey  substance  of  the  posterior  horns.  Irrita- 
tion of  the  grey  substance  of  the  posterior  horns  occasions  the 
cutaneous  trophic  disturbances.  When  the  morbid  change  ex- 
tends to  the  ganglion  cells  of  the  anterior  horns,  atrophy  of  the 
muscles  supplied  from  the  diseased  part  results,  and  it  is  also 
probable  that  the  arthropathies  of  locomotor  ataxia  are  caused 
by  disease  of  the  ganglion  cells  of  the  anterior  horns.  Disease 
of  the  automatic  centres  in  the  lumbar  region  occasions  the 
vesical  and  sexual  disturbances.  When  the  pyramidal  tract 
becomes  implicated  in  the  morbid  change  the  paralytic  stage 
of  the  affection  becomes  established.  Implication  of  the  direct 
cerebellar  tract  is  not  known  to  produce  any  symptoms. 

It  remains  now  to  connect  the  swaying  movements  on  closing 
the  eyes  and  the  ataxia  with  the  morbid  changes  in  the  cord. 
Are  we  to  connect  the  motor  disturbances  in  locomotor  ataxy  with 
disease  of  the  posterior  root-zones  themselves,  or  with  disease 
of  the  fibres  of  the  posterior  roots  and  of  the  posterior  grey 
horns  with  their  consequent  sensory  and  reflex  disturbances  ? 
Vierordt  and  Heyd  have  shown  that  when  the  soles  of  the  feet 
in  healthy  persons  are  rendered  ansesthetic  by  chloroform  or 
ice,  the  amplitude  of  the  oscillations  of  the  body  is  increased. 
This  shows  that  loss  of  cutaneous  sensibility  must  exercise  some 
influence  in  the  production  of  the  motor  disturbances  of  loco- 
motor ataxia,  and  this  influence  becomes  still  greater  when,  as 
frequently  happens,  the  sensibility  of  the  muscles  and  articula- 
tions is  lost. 

But  there  is  no  constant  relation  between  the  degree  of 
ataxia  and  that  of  cutaneous  and  muscular  anaesthesia.  Nume- 
rous cases  are  recorded  in  which  a  high  degree  of  ataxia  was 
present  in  the  absence  of  any  disorder  of  cutaneous  or  muscular 
sensibility,  and  when  both  symptoms  are  present  the}''  do  not 
pursue  a  parallel  course.  It  must,  therefore,  be  concluded  that 
the  ataxia  is  not  caused  by  disease  of  the  fibres  of  the  posterior 
roots  of  the  posterior  grey  horn,  and  that  it  is  caused  by  disease 
of  the  posterior  root-zones  themselves.     These  zones,  as  already 


244  SYSTEM  DISEASES  OF  THE 

mentioned,  consist  of  looped  fibres  which  co-ordinate  afferent 
impulses  before  they  are  transmitted  upwards  to  the  cephalic 
ganglia.  But  the  motor  disturbances  of  locomotor  ataxia  do 
not,  as  we  have  just  seen,  result  from  arrest  of  cerebro-afferent 
impulses  (anaesthesia),  and  it  may  therefore  be  concluded  that 
it  is  caused  by  disease  of  cerebello-afferent  fibres. 

§  447.  Diagnosis. — Typical  cases  of  locomotor  ataxy  are  easy 
to  recognise ;  but  in  those  cases  in  which  the  morbid  process 
extends  beyond  its  usual  limits,  the  diagnosis  is  surrounded  by 
many  difficulties,  and  it  can  only  be  made  by  one  who  has  a 
clear  and  distinct  knowledge  of  the  history  of  the  case  and  of 
the  symptoms  which  implication  of  each  segment  of  the  cord 
occasions.  It  is  also  very  difficult  to  diagnose  tabes  at  its  com- 
mencement, and  yet  it  is  of  great  importance  not  to  overlook 
the  true  nature  of  the  case  in  the  initial  stage.  The  most 
trustworthy  symptoms  are  the  lancinating  pains,  the  feeling  of 
a  tight  girdle,  paralysis  of  the  ocular  muscles,  myosis  with  the 
Argyll-Robertson  symptom,  amaurosis  with  white  atrophy  of 
the  disc,  parsesthesise  in  the  region  of  the  ulnar  nerve,  great 
sense  of  fatigue  on  slight  exertion,  slight  swaying  of  the  body 
on  the  eyes  being  closed,  failure  of  the  patellar-tendon  reflex, 
slight  weakness  of  the  bladder,  and  disturbances  of  the  sexual 
organs. 

The  following  are  the  chronic  spinal  affections  which  are 
most  likely  to  be  mistaken  for  tabes : — 

Common  transverse  myelitis,  as  a  rule,  presents  no  difficulties. 
Paralysis  of  all  the  spinal  functions,  both  motor  and  sensory, 
characterises  this  affection,  and  there  are  no  lancinating  pains 
in  the  initial  stage. 

Multiple  sclerosis  may  sometimes  be  very  similar  in  its 
symptoms  to  locomotor  ataxy.  The  following  symptoms  may 
be  regarded  as  significant  of  multiple  sclerosis :  Great  dizziness, 
headache,  psychical  disturbances,  early  nystagmus,  the  charac- 
teristic tremor  on  voluntary  effort,  paralysis,  muscular  tensions, 
contractures,  increased  reflex  actions  of  tendons  in  the  lower 
extremities,  and  apoplectiform  and  epileptoid  attacks. 

Spasmodic  spinal  paralysis  (lateral  sclerosis)  is  characterised 
by  paresis  and  paralysis  with  muscular  tension  and  contractures, 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  245 

greatly  increased  reflex  action  of  the  tendons,  absence  of  ataxy^ 
and  of  sensory  and  vesical  disturbances,  lancinating  pains,  and 
affections  of  the  cranial  nerves. 

Affections  of  the  cerebellum  may  sometimes  give  rise  to 
symptoms  closely  simulating  locomotor  ataxy.  The  signs  of 
cerebellar  disease  are  severe  headache  especially  in  the  back  of 
the  head,  occasional  vomiting,  general  convulsions,  staggering 
gait  like  that  of  a  drunken  man  or  an  impulse  to  fall  back- 
wards, and  amaurosis,  while  there  is  an  absence  of  lancinating 
pains  or  other  disturbances  of  sensibility,  and  of  the  vesical 
and  sexual  functions. 

Chronic  spinal  meningitis  is  sometimes  complicated  with 
tabes.  The  symptoms  of  meningitis  are  pains  and  stiffness  in 
the  back,  sensitiveness  in  the  spinous  processes  to  pressure,  a 
certain  amount  of  sensory  and  motor  weakness,  and  the  absence 
of  ataxy. 

Progressive  cerebral  paralysis  is  distinguished  from  tabes  by 
the  presence  of  disorders  of  speech  and  psychical  disturbances. 

§  448.  Prognosis.  —  Locomotor  ataxy  is  §i  serious  disease, 
although  the  prognosis  is  not  always  so  serious  as  it  was  once 
thought  to  be.  A  certain  small  per  centage  end  in  recovery, 
and  in  many  instances  the  disease  may  be  arrested  for  years. 
Its  duration  is,  as  a  rule,  always  prolonged,  and  usually  many 
years  elapse  before  the  fatal  termination. 

The  prognosis  is  favourably  influenced  by  the  absence  of  any 
hereditary  predisposition  to  the  disease,  or  of  a  neuropathic 
constitution,  by  a  slow  development  aad  moderate  intensity  of 
the  symptoms,  especially  of  the  sensory  disturbances,  by  the 
patient  being  in  a  comfortable  position  in  life,  and  by  the 
favourable  effect  of  treatment.  If,  on  the  other  hand,  there  be 
a  pronounced  hereditary  predisposition,  if  the  symptoms  make 
rapid  progress,  and  there  be  severe  paroxysms  of  pain,  rapid 
emaciation,  serious  implication  of  the  genito-urinary  organs, 
arthropathies  or  other  trophic  disturbances,  and  implication  of 
the  cranial  nerves,  the  prognosis  is  unfavourable. 

The  prognosis  of  individual  symptoms  is  very  various. 
The  disturbances  of  sensibility  usually  readily  improve,  but 
the  prognosis  of  the  ataxy  is  unfavourable.     The  lancinating 


246  SYSTEM  DISEASES   OF  THE 

pains  and  the  sexual  weakness  are  usually  very  obstinate,  but 
the  vesical  troubles  may  disappear.  The  prognosis  in  paralysis 
of  the  muscles  of  the  eye  is  favourable,  but  the  amaurosis,  due 
to  atrophy  of  the  optic  nerve,  is  quite  hopeless. 

§  449.  Treatment. — When  there  is  a  manifest  predisposition 
to  locomotor  ataxy,  the  members  of  the  family  should  be  sub- 
jected to  a  careful  regimen  with  the  view  of  preventing  the 
development  of  the  disease.  Members  of  such  families  should 
be  cautioned  against  exposing  themselves  to  the  exciting  causes 
of  the  disease,  such  as  cold  and  damp,  venereal  excesses,  and 
onanism. 

Antiphlogistic  treatment  may  be  useful  in  the  very  early 
stage  of  those  cases  which  are  complicated  by  spinal  meningitis, 
but  it  does  no  good  in  any  other  case.  Counter-irritants  have 
been  greatly  employed  in  the  treatment  of  tabes,  but  they  have 
never  been  found  to  be  of  any  use,  except  probably  in  those 
cases  which  were  complicated  by  spinal  meningitis.  Thermal 
baths  have  been  much  used  at  one  time,  but  they  are  probably 
injurious  instead  of  being  beneficial,  except  in  those  cases  which 
are  attended  by  lancinating  pains  of  unusual  severity,  and  in 
which  there  are  general  excitability,  sleeplessness,  and  other 
symptoms  of  irritation.  The  temperature  should  never  be 
above  90°  F.,  and  the  patient  should  not  remain  in  the  bath 
longer  than  from  fifteen  to  twenty  minutes,  and  it  should  be 
used  only  once  in  two  or  three  days  (Erb). 

Sulphur  baths  have  been  much  used  in  France,  and  the 
effects  obtained  from  them  have  been  favourably  reported  on. 
They  have  only,  however,  been  used  as  adjuncts  along  with 
other  agents,  so  it  is  impossible  to  tell  how  much  of  the  effect 
is  to  be  attributed  to  them. 

Saline  thermal  baths  appear  to  act  favourably  on  the  disease. 
Rheims  has  long  enjoyed  a  reputation  in  the  treatment  of  tabes, 
and  Erb  reports  favourably  of  Nanheim.  Chalybeate  and  mud 
baths  have  been  employed  in  the  treatment  of  the  disease,  but 
it  is  doubtful  if  they  possess  any  special  advantages. 

The  cold-water  cure,  in  well-conducted  hydropathic  establish- 
ments, is  probably  one  of  the  very  best  methods  of  treating  the 
disease.     Almost  all  authorities  on  nervous  diseases,  with  the 


SPINAL  COED  AND  MEDULLA  OBLONGATA.  247 

exception  of  Leyden,  speak  most  favourably  of  the  beneficial 
action  of  hydro-therapeutics,  and  Erb  recommends  his  patients 
to  use  the  cold  sponge  bath  at  home  all  winter.  The  wet  pack 
should  be  used  with  caution,  beginning  with  a  temperature  of 
88°  F.  and  going  down  to  77°  F.  Wet  rubbings,  beginning  at  a 
temperature  of  77°  F.  and  going  down  to  65°  F.  do  good.  The 
institutions  to  which  patients  affected  with  tabes  are  sent 
should  be  situated  in  mountainous  regions  and  provided  with 
convenient  walks.  Patients  should  be  sent  there  in  the  be- 
ginning of  summer  with  instructions  to  remain  till  autumn. 

Electro-therapeutics  unquestionably  exercise  a  favourable 
influence  on  the  progress  of  the  disease.  The  constant  current 
is  usually  employed.  Both  electrodes  should  be  placed  on  the 
vertebral  column — one  in  the  lumbar  region,  and  the  other  at 
the  nucha.  The  direction  of  the  current  appears  to  be  an  in- 
different matter,  but  an  ascending  current  is  generally  preferred. 
One  pole,  say  the  lower,  should  be  fixed,  and  the  other  slowly 
moved  along  the  back  so  as  to  come  in  contact  with  every  part 
of  the  vertebral  column ;  then  the  upper  pole  should  be  fixed, 
while  the  lower  one  should  be  slowly  moved  along  the  back. 
Peripheral  galvanisation  of  the  nerves  of  the  lower  extremities 
by  cathode  labile  currents  may  be  combined  with  the  galvanic 
treatment  of  the  spine.  In  irritable  persons  with  severe  pains 
the  currents  employed  should  be  very  weak,  and  strong  currents 
should  be  avoided  on  all  occasions.  The  galvanic  current  should 
be  employed  daily,  but  each  sitting  should  not  be  for  more  than 
from  three  to  six  minutes'  duration.  Galvanic  treatment  should 
be  discontinued  if  the  patients  feel  fatigued  after  each  sitting, 
if  the  pains  increase,  and  if  the  condition  of  the  patient  becomes 
gradually  worse. 

Of  interna]  remedies  the  nitrate  of  silver  has  acquired  the 
greatest  reputation  in  the  treatment  of  tabes,  and  most  authors 
are  agreed  that  it  frequently  produces  a  beneficial  effect. 
Friedreich  has  recently  drawn  attention  to  the  fact  that  its 
long-continued  use  may  induce  albuminuria,  but  moderate 
doses  may  be  taken  for  a  considerable  time  without  producing 
any  deleterious  effect.  It  should  be  given  in  doses  of  one-sixth 
to  one-third  of  a  grain  three  times  a  day.  It  may  be  continued 
for  three  weeks  at  a  time,  and  then  after  an  interruption  for  two 


248  SYSTEM  DISEASES  OF  THE 

weeks  its  use  may  be  resumed  for  anotlier  three  weeks.  The 
use  of  the  medicine  may  be  continued  in  this  way  with  repeated 
interruptions  for  many  months  without  producing  any  delete- 
rious effects.  If  the  skin  shows  the  slightest  discolouration,  the 
medicine  must,  of  course,  be  interrupted  for  a  longer  period. 

The  iodide  of  potassium  given  in  large  doses  has  sometimes 
been  found  of  benefit,  especially  in  those  cases  which  are  com- 
plicated with  meningitis.  The  bromide  of  potassium  in  large 
doses  is  also  said  to  be  of  use  in  mitigating  the  pains. 

Belladonna  and  ergot  of  rye  have  been  tried  in  tabes,  but 
neither  of  them  appear  to  have  been  productive  of  good ;  and 
the  same  may  be  said  of  arsenic,  chloride  of  gold  and  sodium, 
and  chloride  of  barium.  Strychnia  should  on  no  account  be 
administered,  as  it  always  appears  to  do  harm.  Phosphorus 
has  been  found  to  have  a  beneficial  effect  occasionally,  especially 
in  cases  where  the  sensibility  is  greatly  affected. 

God-liver  oil  is  strongly  recommended  by  many  authors,  and 
in  many  cases  its  employment  is  attended  with  great  benefit. 

Esmarch  made  a  communication  of  great  importance  at  a 
recent  surgical  congress  at  Berlin.  In  a  case  which  was 
diagnosed  by  Professor  Quinke  as  locomotor  ataxia,  and  in  which 
the  lancinating  pains  attained  their  greatest  severity  in  the 
forearm,  Crede,  of  Dresden,  stretched  the  nerves  in  the  axilla, 
and  the  pains  and  ataxic  symptoms  disappeared. 

The  diet  and  method  of  life  should  be  carefully  regulated 
in  tabes.  Patients  should  have  as  much  fresh  air  as  possible, 
especially  mountain  and  sea  air,  and  that  of  forests. 

Patients  should  be  particularly  careful  not  to  over-exert 
themselves,  although  a  certain  amount  of  graduated  muscular 
exercise  has  a  beneficial  effect.  Patients  must  of  course  be 
carefully  guarded  against  exposure  to  cold  and  damp ;  and 
should,  therefore,  be  particular  to  wear  warm  clothing  and 
flannel  next  to  the  skin.  In  old  cases  patients  should  be  dis- 
couraged from  all  useless  attempts  at  curative  treatment.  The 
existence  of  the  patient  must  be  rendered  as  pleasant  as  pos- 
sible, and  the  treatment  may  be  directed  to  sustain  the  general 
health,  but  it  is  quite  useless  to  adopt  any  special  treatment. 

In  such  a  long  and  tedious  illness  symptomatic  treatment 
will  have  to  be  adopted  in  the  course  of  the  disease.     For  the 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  249 

lancinating  pains  a  large  number  of  remedies  have  been  em- 
ployed at  various  times.  Amongst  these  may  be  mentioned 
synapisms,  blisters,  warmth,  Priessnitz's  cold-water  compresses, 
belladonna  plasters,  rubbing  with  chloroform,  faradisation  or 
galvanisation  (stabile  anode)  of  the  hyperaesthetic  spots,  sub- 
cutaneous injections  of  morphia,  large  doses  of  the  bromide  of 
potassium,  of  the  hydro-bromide  of  quinine,  and,  when  there  is 
meningitis,  large  doses  of  the  iodide  of  potassium. 

Electricity  is  the  only  remedy  for  cutaneous  ansesthesia, 
motor  weakness,  and  atrophy  of  the  muscles. 

In  vesical  weakness  faradisation  of  the  bladder,  either 
with  or  without  the  aid  of  the  bladder  electrode,  is  useful. 
Cystitis  must  be  treated  in  the  same  way  as  chronic  myelitis. 
For  the  amaurosis  no  treatment  appears  to  be  of  any  avail. 

Constipation  is  sometimes  a  very  troublesome  symptom. 
The  diet  should  be  carefully  regulated,  with  the  view  of  acting 
upon  the  bowels,  and  enemata  may  be  employed  as  aids  to 
treatment.  If  necessary,  mild  aperients  may  be  used;  but  all 
purgatives  should,  as  far  as  possible,  be  avoided. 

In  obstinate  cases  faradisation  of  the  bowels  may  be  of  great 
use.  (j 

2.  Sclerosis  of  the  Columns  of  Goll. 
(a)  Primary  Sclerosis  op  the  Columns  op  Goll. 
§  450.  The  most  notable  example  of  primary  sclerosis  of  the 
columns  of  Goll  is  a  case  observed  by  Pierrot.  The  following  is  a 
brief  abstract  of  the  symptoms  recorded  : — Margaret  Magnaigat, 
set.  30  years,  experienced  numbness,  formication,  sensations  of 
heat,  and  deep-seated  pain  in  the  limbs,  more  especially  in  the 
upper  extremities.  There  were  also  obstinate  headache,  pains  in 
the  loins,  and  a  sense  of  constriction  of  the  thorax.  In  1860  she 
did  not  feel  the  ground  distinctly  with  her  feet,  and  she  was 
obliged  to  walk  with  a  cane,  and  three  years  later  she  entered 
the  Salpetriere  under  the  care  of  Charcot.  Tactile  sensibility 
was  then  diminished  in  the  sole  of  the  feet,  which  she  detached 
with  difficulty  from  the  ground.  These  symptoms  were  especially 
marked  in  the  left  foot,  and  she  could  not  walk  without  the  use 
of  a  crutch  under  the  right  axilla.  When  she  wished  to  advance 
she  felt  as  if  she  were  being  drawn  backwards,  but  once  started 


250  SYSTEM  DISEASES  OF  THE 

she  was  impelled  forwards  by  a  force  she  could  not  control.  She 
could  maintain  the  erect  posture  with  closed  eyes,  but  felt  ready 
to  fall  at  every  instant.  In  1866  she  complained  of  girdle  sen- 
sations, and  lightning  pains  passing  round  the  body  and  down 
the  anterior  part  of  the  thighs,  while  she  was  readily  fatigued, 
but  the  muscular  sense  was  unaffected.  She  died  in  1871  from 
an  attack  of  pDcumonia.  At  the  autopsy  Pierret  found  sclerosis 
of  the  columns  of  Goll,  and  he  thinks  that  disease  of  these 
columns  explains  the  tendency  to  propulsion  and  retropropulsion 
experienced  by  the  patient  as  well  as  the  uncertainty  felt  in 
maintaining  the  erect  posture.  The  posterior  root-zones  were 
to  some  extent  implicated  in  the  lesion  in  the  dorsal  region,  and 
I  should  say,  from  the  careful  drawings  which  accompany  the 
case,  in  the  lumbar  region  also.  Implication  of  the  posterior 
root-zones  doubtless  explains  the  lightning  pains  and  other 
sensory  disturbances  present  during  the  progress  of  the  case. 
A  case  of  primary  sclerosis  of  the  columns  of  Goll  has  been  re- 
corded by  Ducastel  and  another  by  Gowers,  but  in  neither  were 
there  symptoms  during  life  which  could  with  probability  be 
attributed  to  disease  of  these  columns. 

(6)  Secondary  Sclerosis  of  the  Columns  op  Goll. 

§  451.  Secondary  sclerosis  of  the  columns  of  Goll  occurs  in 
coonection  with  transverse  myelitis,  and  it  is  then  called  ascend  - 
ing  sclerosis  (§  890,  a).  It  is  also,  as  we  have  just  seen,  usually 
associated  with  sclerosis  of  the  posterior  root- zones  in  locomotor 
ataxia,  and  is  often  observed  in  many  of  the  compound  lesions 
of  the  cord.  In  none  of  these  cases,  however,  has  the  affection 
of  the  columns  of  Goll  ever  been  connected  with  any  definite 
symptoms. 

3.  Sclerosis  of  the  Direct  Cerehellar  Tracts. 

§  452.  Sclerosis  of  the  direct  cerebellar  tracts  is,  so  far  as 
is  known,  always  secondary  and  ascending.  It  occurs  in  trans- 
verse myelitis  along  with  sclerosis  of  the  columns  of  Goll 
(§  390,  a).  These  tracts  are  also  diseased  in  cases  of  meningo- 
myelitis,  or  what  is  called  cortical  or  ring-shaped  sclerosis. 
Disease  of  these  tracts  has  never  been  connected  with  any 
symptoms  during  life. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  251 

4.  Lateral  Sclerosis, 
(a)  Primary  Lateral  Sclerosis. 

Tabes  Dorsalis  Spasmodica  (Charcot).     Spasmodic  Spinal  Paralysis. 

§  453.  Definition.  —  The  disease  is  characterised  by  a 
progressive  paresis  advancing  gradually  from  below  upwards, 
accompanied  by  muscular  tension,  contractures,  and  increase  of 
the  tendinous  reflexes,  along  with  entire  absence  of  sensory  and 
nutritive  disturbances. 

§  454.  Etiology. — No  very  decided  hereditary  tendency  to  the 
affection  has  as  yet  been  made  out.  It  appears  to  occur  rather 
more  frequently  in  males  than  females. 

With  respect  to  age,  by  far  the  largest  number  of  cases  begin 
between  the  ages  of  thirty  and  fifty.  The  disease  is  occasionally 
observed  in  childhood,  a  fact  which  might  suggest  the  existence 
of  a  congenital  defect  of  some  parts  of  the  spinal  cord. 

The  exciting  causes  of  the  affection  are  unknown,  although  it 
is  very  probable  that  exposure  to  cold,  injuries  to  the  spine, 
lead  poisoning,  and  syphilis  may  co-operate  as  factors  in  the 
production  of  the  disease. 

§  455.  Symptoms. — The  first  and  for  a  long  time  the  only 
symptom  is  a  paresis  of  the  inferior  extremities,  which  may  be 
equal  in  both  or  more  pronounced  in  one  of  them,  and  the  only 
effect  of  which  is  to  render  walking  somewhat  difficult,  especially 
immediately  on  getting  out  of  bed  in  the  morning.  The  patients 
complain  that  they  are  soon  fatigued,  that  their  limbs  are  heavy, 
and  their  gait  becomes  dragging  and  diflicult.  It  is  only  in  the 
later  stages  of  the  affection  that  the  paresis  increases  to  com- 
plete paralysis.  JM  anifestations  of  motor  irritation  now  ally 
themselves  with  the  motor  weakness.  On  lying  down  and 
especially  in  bed  at  night,  on;  after  being  fatigued,  the  legs 
become  subject  to  clonic  or  tonic  spasms.  The  former  produce 
tremors,  which  sometimes  remain  limited  to  the  extremities 
but  are  at  other  times  so  violent  as  to  be  communicated  to 
the  entire  body.  These  may  be  readily  excited  by  pushing 
against  the  toes  so  as  to  produce  dorsal  flexion  of  the  foot 
(Ankle  Clonus,  §  80).  After  a  time  distinct  muscular  tension 
is  developed.     On  passive  movements  of  the  lower  extremities 


252  SYSTEM  DISEASES  OF  THE 

the  muscles  become  tense,  but  in  the  early  stages  of  the 
affection  the  muscular  tension  can  be  readily  overcome  by 
increasing  the  pressure,  while  it  can  be  considerably  diminished 
by  repeated  movements.  The  muscular  tension  soon  shows  itself 
on  voluntary  movements  being  made,  rendering  them  difficult 
and  uncertain,  and  making  the  degree  of  paresis  appear  greater 
than  it  is  in  reality. 

After  a  time  the  muscular  tension  increases  to  permanent 
rigidity,  and  a  high  degree  of  contracture  results.  The  legs  are 
maintained  in  a  position  of  rigid  extension,  the  thighs  being 
also  held  rigidly  together  by  contracture  of  the  adductors,  the 
feet  are  in  a  position  of  extreme  talipes  equino- varus,  and  the 
toes  are  generally  strongly  flexed.  The  rigid  immobility  of  the 
feet  is  now  and  then  interrupted  by  clonic  trembling,  which 
may  extend  to  the  entire  leg.  The  trembling  may  appear  to 
arise  spontaneously,  but  is  nearly  always  caused  either  by  a 
reflex  or  voluntary  movement  of  the  foot. 

The  Spasmodic  Gait  or  Spastic  Walk. — The  combined 
paresis,  stiffness,  and  tremors  of  the  lower  extremities  render 
the  gait  quite  characteristic.  The  foot  seems  to  cling  to  the 
ground,  from  which  it  is  detached  with  difficulty,  and  as  it  is 
made  to  slide  forwards  it  produces  a  characteristic  scraping 
noise ;  while  the  toes  find  an  obstacle  in  every  elevation  of  the 
ground,  and  the  patient  readily  stumbles  and  falls.  Owing  to 
the  contracture  of  the  extensors  of  the  lower  extremity  the 
limbs  are  held  in  a  rigid  condition  at  all  the  articulations,  so 
that  the  necessary  elevation  of  the  passive  leg  is  obtained  by 
an  upward  rotation  of  the  pelvis,  caused  by  contraction  of  the 
abductors  of  the  thigh  on  the  side  of  the  active  leg.  The  body 
is  consequently  strongly  inclined  at  each  step  to  the  side  of 
the  active  leg.  The  movement  of  the  passive  foot  is  not,  how- 
ever, directly  forwards.  The  predominant  contraction  of  the 
adductors  of  the  thigh  over  the  abductors  causes  the  legs  to  be 
drawn  energetically  towards  one  another,  while  the  foot  is 
sometimes  though  not  always  inverted,  owing  to  the  strong  con- 
tracture of  the  inward  rotators  of  the  thigh.  The  consequence 
is  that  the  toe  of  the  leg  about  to  be  moved  forwards  often  gets 
entangled  against  the  heel  of  the  active  leg,  and  the  trunk  has 
to  be  strongly  inclined  towards  that  side  so  as  to  give  additional 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  253 

purchase  to  the  abductors  of  the  opposite  thigh,  and  thus 
enable  them  to  move  the  foot  outwards  and  away  from  the 
other.  The  passive  leg  is,  therefore,  moved  outwards  and 
forwards  in  a  semicircle,  and  when  it  is  brought  to  the  ground 
it  generally  crosses  over  to  the  opposite  side  in  front  of  the 
other  foot.  It  will  be  observed  that  at  each  step  the  body  is 
strongly  inclined  towards  the  side  of  the  active  leg,  and  con- 
sequently the  gait  is  somewhat  "  waddling,"  and  is  in  this 
respect,  as  Hammond  remarks,  like  that  of  a  woman  with  a 
wide  pelvis.. 

At  this  period  the  weight  of  the  body  suffices  to  arrest  the 
clonic  contractions  of  the  muscles  of  the  calf  of  the  active  leg, 
but  the  passive  leg  is  often  agitated  by  tremors,  which  greatly 
add  to  the  difficulty  of  progression.  As  the  disease,  however, 
increases,  the  spasmodic  rigidity  of  the  muscles  of  the  calf  be- 
comes so  great  that  the  patient  rests  upon  the  tips  of  his  feet; 
while  the  body  is  inclined  forwards,  the  arms  being  propped  up 
by  crutches,  or  supported  by  two  sticks,  which  are  held  well  in 
front  of  the  patient  with  an  outward  inclination.  The  contrac- 
ture of  the  muscles  of  the  calf  is  now  so  pronounced  that  the 
weight  of  the  body  does  not  suffice  to  prevent  ankle  clonus  from 
taking  place,  and,  consequently,  when  the  patient  first  attains 
the  erect  posture,  his  heels  become  strongly  elevated,  probable 
to  the  extent  of  6  inches  from  the  ground.  After  the  first 
elevation  the  heel  is  in  some  cases  almost  immediately  lowered 
to  the  extent  of  about  1  to  1|  inches,  and  this  in  its  turn  is 
succeeded  by  another  elevation  and  so  on  in  rhythmical  sequence. 
The  heels  and  with  them  the  whole  body  are  thus  elevated  and 
depressed  7  or  8  times  or  more  in  rapid  succession,  the  number 
of  these  elevations  which  take  place  in  a  second  of  time  corre- 
sponding to  those  of  the  ankle  clonus  already  described. 

After  a  time  the  upward  and  downward  movements  of  the 
body  cease,  the  heels  come  closer  to  the  ground  although 
they  do  not  come  in  contact  with  it,  and  the  patient  now 
endeavours  to  move  forwards  one  leg,  say  the  right.  The  first 
step  may  be  performed  with  tolerable  facility,  but  when  once 
the  right  foot  is  projected  forwards  it  crosses  over  to  the  other 
side,  and  is  brought  to  the  ground  in  front  of  the  left  foot. 
When  the  left  has  now  to  be  advanced  the  greatest  difficulty  is 


254)  SYSTEM  DISEASES   OF  THE 

experienced  in  disengaging  the  toe  from  the  heel  of  the  right 
foot,  and  in  the  effort  to  do  so  the  muscles  of  the  calves  of  both 
legs  become  strongly  contracted,  the  patient  is  elevated  on  tip- 
toes, and  every  effort  to  abduct  the  left  foot  so  as  to  move  it 
away  from  the  other  may  induce  clonus  of  the  right  ankle,  and 
consequent  elevations  and  depressions  of  the  body.  When  at 
last  the  left  foot  is  disengaged,  and  is  being  moved  forwards 
in  the  semicircular  manner  already  described,  it  is  generally 
seized  with  trembling  (partly  consisting  of  ankle  clonus  and 
partly  of  tendinous  reflex  contractions  of  the  muscles),  which 
extends  to  the  trunk,  and  throws  the  whole  body  into  violent 
agitation.  This  description  only  applies  of  course  to  the  severer 
cases,  and  if  the  muscular  contracture  increases  beyond  this 
point  walking  becomes  impossible.  In  less  aggravated  cases 
one  sudden  elevation  of  the  heel  of  the  active  leg  may  be 
followed  by  a  depression  without  subsequent  elevation,  so  that 
the  gait  has  a  peculiar  hopping  character. 

The  disease  extends  slowly  and  gradually  upwards  until  the 
superior  extremities  are  implicated.  The  lumbar  and  abdominal 
muscles  are  also  affected,  the  abdomen  becomes  prominent,  hard, 
and  separated  from  the  base  of  the  thorax  by  a  horizontal  fold 
of  more  or  less  depth,  while  at  the  same  time  a  kind  of  lordosis 
is  produced. 

When  the  upper  extremities  are  affected,  the  paretic  con- 
dition of  the  hands  manifests  itself  by  the  inaptitude  of  the 
patient  to  seize  small  objects.  The  digits  from  time  to  time 
become  flexed  involuntarily  into  the  palm  of  the  hand;  while 
at  a  later  period  of  the  disease  the  fingers  become  perma- 
nently flexed.  The  muscles  acting  on  the  wrist  and  elbow 
are  successively  affected,  and  the  forearm  and  hand  become 
rigid  in  a  condition  of  extension  and  pronation.  The  superior 
extremities  are  now  rigid  and  immobile,  and  more  or  less 
strongly  drawn  to  each  side  of  the  body,  but  the  tremors  are 
never  so  pronounced  in  them  as  in  the  lower  extremities. 
Although  this  is  the  usual  course  of  the  disease,  yet  occasionally 
the  symptoms  are  developed  in  a  different  order.  At  times  the 
affection  passes  first  from  one  lower  extremity  to  the  upper 
extremity  of  the  same  side,  and  this  hemiplegic  condition  may 
persist   for  many  years  before   the  other  lower  extremity  is 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  255 

attacked.  Sometimes  the  disease  begins  in  the  upper  extre- 
mities, progresses  downwards,  and  does  not  involve  the  lower 
extremities  until  a  later  period. 

The  paralysis  after  a  time  becomes  complete,  the  contractures 
increase  in  intensity,  the  patients  grow  stiff  and  immovable, 
and  are  doomed  to  keep  their  beds.  But  even  in  patients  who 
are  bedridden  for  years  the  general  health  is  good,  and  it  does 
not  appear  that  the  disease  ever  directly  causes  death,  which 
generally  results  from  an  intercurrent  affection. 

The  tendinous  and  periosteal  reflexes  are  greatly  exaggerated 
in  this  disease.  The  patellar-tendon  reflex  and  ankle  clonus 
can  be  elicited  in  the  usual  way  with  undue  readiness.  The 
quadriceps  femoris  and  the  adductors  of  the  thigh  may  be 
excited  to  contract  by  tapping  the  broad  upper  end  of  the  tibia, 
and  the  contractions  may  extend  even  to  the  adductors  of  the 
opposite  thigh.  The  adductors  of  the  thigh  may  also  often  be 
made  to  contract  by  tapping  over  the  region  of  the  lumbar 
vertebras.  Tendon  reflexes  also  occur  in  the  tibialis  posticus, 
semi-tendinosus,  and  other  muscles. 

The  tendon  reflexes  are  in  like  manner  increased  in  the  upper 
extremities  when  they  become  implicated.  They  can  be  elicited 
in  the  biceps  and  triceps  by  striking  the  tendons,  while  the  former 
may  be  made  to  contract  by  tapping  the  lower  end  of  the  radius, 
and  the  latter  by  tapping  the  lower  end  of  the  ulna.  The  pos- 
terior portion  of  the  deltoid  often  contracts  along  with  the  triceps, 
when  the  lower  end  of  the  ulna  is  lightly  struck.  The  flexors  of 
the  fingers,  the  extensors  of  the  wrist,  and  the  supinator  longus 
can  each  be  made  to  contract  by  tapping  their  tendons  at  t\\e 
wrist ;  while  the  interossei  may  sometimes  be  made  to  contract 
by  tapping  the  ends  of  the  metacarpal  bones.  The  deltoid  may 
be  made  to  contract  by  tapping  the  spine  of  the  scapula,  and  the 
pectoralis  major  by  tapping  the  sternum. 

The  cutaneous  reflex  appears  to  be  occasionally  increased, 
but  it  is  generally  normal  or  diminished. 

The  electrical  excitability  of  the  motor  nerves  may  manifest 
slight  quantitative  but  never  any  qualitative  changes.  The 
faradic  and  galvanic  excitability  of  the  muscles  is  generally 
diminished  (Erb). 

Sensory  disturbances  are  entirely  absent  in  this   disease, 


256  SYSTEM  DISEASES  OF  THE 

the  various  forms  of  cutaoeous  and  muscular  sensibility  being 
normal.  The  patient  does  not  complain  of  parsesthesise,  girdle 
sensations,  lancinating  pains,  or  the  affections  of  the  cranial 
nerves,  which  are  so  common  in  locomotor  ataxia.  The  func-. 
tions  of  the  bladder,  rectum,  and  sexual  organs  are  entirely 
unaffected.  Yaso-motor  disturbances  are  absent,  and  there  are 
no  nutritive  affections  of  the  muscles  or  skin,  and  no  bed-sores. 

§  456.  Course,  Duration,  and  Terminations. — The  course  of 
the  disease  is  generally  very  chronic.  It  comes  on  in  a  very 
insidious  manner,  and  months  or  years  may  elapse  before  the 
affection  can  be  recognised  with  certainty.  Occasionally  the 
symptoms  become  developed  in  a  typical  manner  in  a  com- 
paratively brief  space  of  time,  and  it  may  then  remain  stationary 
for  a  long  period. 

The  duration  of  the  disease  is  nearly  always  long,  extending 
over  many  years.  Complicated  cases  may  run  a  comparatively 
rapid  course. 

The  disease  occasionally  terminates  in  recovery.  Heuck 
reports  a  case  of  spastic  spinal  paralysis  which  began  suddenly 
with  acute  and  violent  pains  in  the  back,  and  terminated,  after 
a  duration  of  five  weeks,  in  complete  recovery.  Death  generally 
occurs  from  accidental  causes  or  intercurrent  diseases. 

(6)  Compound  Lateral  Sclerosis. 
(i.)    amyotrophic    lateral    sclerosis. 

ScUrose  LaUrale  Amyotrophique  (Charcot). 

•  §  457.  Symptoms. — Spasmodic  spinal  paralysis  may  be  com- 
plicated with  every  degree  of  progressive  muscular  atrophy; 
bat  the  highest  degree  of  this  combination  is  presented  by  those 
cases  which  have  been  described  by  Charcot,  under  the  name 
of  sclerose  lat^rale  amyotrophique. 

The  disease  generally  begins,  according  to  Charcot,  in  the 
upper  extremities  by  motor  weakness,  accompanied  by  a  rapid 
muscular  wasting,  which  extends  uoiformly  to  all  the  muscles 
of  the  affected  limbs.  The  symptoms  of  paresis  may  be  pre- 
ceded by  formication  and  numbness  in  the  upper  extremities, 
and  the  atrophy  is  accompanied  by  fibrillary  twitch ings  of  the 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  257 

affected  muscles.  Muscular  tension  and  contractures  are  soon 
superadded  to  the  paresis  and  atrophy,  and  the  affected  ex- 
tremities are  brought  into  permanently  deformed  positions. 
The  arm  is  applied  to  the  trunk,  the  forearm  is  semi-flexed  and 
pronated,  and  it  is  not  possible  to  supinate  or  extend  it  without 
employing  a  considerable  degree  of  force  and  causing  pain,  the 
hand  is  flexed  on  the  forearm,  and  the  different  segments  of  the 
fingers  are  flexed  upon  one  another  and  upon  the  metacarpal 

Fig.  178. 


Fig.  178  (After  Charcot).     Attitude  of  the  Hand  and  Forearm  in 
Amyotrophic  Lateral  Sclerosis, 

bones.  When  the  patient  elevates  the  arm  by  a  voluntary 
effort,  the  extremity  becomes  agitated  by  tremors,  not  unlike 
those  which  occur  in  sclerosis  in  patches.  In  advanced  cases 
the  thenar  and  hypothenar  eminences  become  flattened,  the 
palm  of  the  hand  becomes  excavated,  and  the  muscular  atrophy 
may  proceed  so  far  that  the  forearm  and  arm  are  reduced  almost 
to  a  skeleton.  Under  these  circumstances  the  spasmodic  rigidity 
becomes  less  pronounced,  but  the  limbs  may  even  then  main- 
tain the  forced  attitudes  in  which  they  have  been  held  so  long. 

In  some  patients  the  head  is  fixed  by  spasmodic  rigidity  of 
the  muscles  of  the  neck  so  that  they  cannot  move  it  in  any 
direction.  The  contracture  may  also  extend  to  the  temporal 
muscles  so  that  the  mouth  can  only  be  opened  to  a  limited 
degree  (Charcot).  The  muscular  atrophy  may  occasionally  be 
masked  by  a  pseudo-hypertrophy  of  the  affected  muscles. 


258  SYSTEM  DISEASES  OF  THE 

After  a  period  of  from  two  to  six  or  nine  months  the  lower 
extremities  become  affected,  first  by  paresis,  which  may  be  pre- 
ceded or  accompanied  for  a  longer  or  shorter  time  by  formication 
and  numbness  of  the  limbs.  The  paresis  of  the  lower  extremi- 
ties is  not,  as  occurs  in  the  upper  extremities,  necessarily  accom- 
panied by  atrophy  of  the  muscles.  It  is,  however,  accompanied 
by  muscular  tension,  permanent  contractures  which  maintain 
the  extremities  rigid  in  the  position  of  extension,  by  tremors, 
ankle  clonus,  and  increased  reflex  action  of  tendons.  These 
symptoms  are,  indeed,  those  which  have  already  been  described 
as  belonging  to  primary  lateral  sclerosis,  and  they  soon  increase 
to  such  a  degree  in  the  amyotrophic  varieties  as  to  render 
walking  impossible.  At  first  the  muscles  of  the  lower  extremi- 
ties are  tense  and  firm,  and  do  not  show  any  trace  of  atrophy, 
but  after  a  time  fibrillary  contractions  occur,  diffused  atrophy 
of  the  muscles  supervene,  and  the  contractures  diminish. 

The  third  stage  of  the  disease  is  characterised  by  the  appear- 
ance of  bulbar  paralysis,  consisting  in  paralysis  of  the  tongue 
and  lips,  and  of  the  pharyngeal  and  laryngeal  muscles.  The 
nuclei  of  the  pneumogastric  nerves  appear  finally  to  be  in- 
vaded, giving  rise  to  disturbances  of  circulation  and  respiration 
which  before  long  induce  death.  The  disease  develops  rapidly, 
and,  according  to  Charcot,  always  causes  death  in  from  one  to 
three  years ;  differing  in  this  respect  greatly  from  progressive 
muscular  atrophy,  which  may  extend  over  a  period  of  from 
eight  to  twenty  years. 


(ii.)  COMBINED  SCLEROSIS  OF  THE  POSTEEIOB  AND  LATERAL  COLUMNS. 

§  458.  The  symptoms  of  locomotor  ataxy  and  of  primary 
lateral  sclerosis  may  be  present  in  every  possible  combination ; 
those  of  the  former  predominating  at  one  time  and  of  the  latter 
at  another.  The  symptoms  which  indicate  that  the  lateral 
columns  are  being  gradually  invaded  in  locomotor  ataxy  are 
spontaneous  jerkiogs  in  the  lower  extremities,  gradual  loss  of 
power  to  perform  simple  movements  of  extension  and  flexion, 
muscular  tension,  and  contractures. 

When,  on  the  other  hand,  the  symptoms  of  lateral  sclerosis 
predominate,  the  signs  by  which  a  complication  of  locomotor 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  259 

ataxy  may  be  suspected  are  the  presence  of  lancinating  pains, 
girdle  pains,  and  other  sensory  disturbances,  vesical  weakness, 
slight  swaying  on  closing  the  eyes,  and,  above  all,  the  absence 
of  the  patellar-tendon  reflex  and  ankle  clonus. 


(c)  Secondary  Lateral  Sclerosis. 

§  459.  Lateral  sclerosis  occurs  as  a  secondary  disease  in 
transverse  myelitis  and  in  various  diseases  of  the  medulla 
oblongata,  pons,  and  brain.  It  always  occurs  below  the  seat  of 
the  lesion,  and  pursues  a  descending  course  (§  390,  6).  The 
symptoms  caused  by  secondary  lateral  sclerosis  are  the  same  as 
those  caused  by  the  primary  form  of  the  affection,  being  only 
modified  by  the  symptoms  of  the  primary  lesion  with  which  it 
is  associated.  These  symptoms  are,  briefly,  voluntary  paralysis, 
muscular  tension  and  contracture,  excess  of  the  deep  reflexes, 
and  generally  also  of  the  cutaneous  reflexes.  The  symptoms 
of  secondary  degeneration  of  the  pyramidal  tracts  will  be  more 
minutely  described  when  the  primary  lesions  with  which  it  is 
associated  are  under  discussion. 

§  460.  Morbid  Anatomy.— The  morbid  anatomy  of  primary 
lateral  sclerosis  has  given  rise  to  a  good  deal  of  discussion,  and 
no  post-mortem  examination  of  an  uncomplicated  case  of  the 
disease  has  hitherto  been  published.  But  what  we  know 
of  the  functions  of  the  lateral  columns  renders  it  probable 
that  the  anatomical  basis  of  the  affection  consists  of  sym- 
metrical sclerosis  of  the  lateral  columns.  Leyden  has,  however, 
advanced  powerful  arguments  against  this  opinion.  Two  cases 
have  been  published  by  Charcot  and  Pitres,  one  of  which  was 
diagnosed  during  life  as  amyotrophic  lateral  sclerosis,  and 
the  other  as  primary  lateral  sclerosis,  and  the  post-mortem 
examination  showed  that  both  were  anomalous  cases  of  sclerosis 
in  patches.  The  French  authors,  however,  acknowledge  that 
in  the  case  which  was  diagnosed  during  life  as  primary  lateral 
sclerosis  the  symptoms  were  not  quite  characteristic.  Symptoms, 
for  instance,  of  vesical  weakness  and  slight  sensory  disturbances 
were  present,  and  the  authors  think  that  had  sufficient  weight 
been  given  to  the  presence  of  these  symptoms  the  diagnosis  of 


260  SYSTEM  DISEASES   OF -THE 

primary  lateral  sclerosis  would  not  have  been  made.  And, 
again,  although  a  focus  of  disease  was  found  in  the  posterior 
columns  in  the  cervical  region  of  the  cord,  the  other  foci  were 
found  in  the  pyramidal  tracts  in  their  passage  through  the 
crusta,  anterior  pyramids  of  the  medulla,  and  lateral  columns 
of  the  cord.  Charcot,  therefore,  thinks  that  this  case  confirms  to 
some  extent  the  theory  of  symmetrical  sclerosis  of  the  lateral 
columns.  Dr.  Carl  Ritter  von  Stofella  has  published  a  case  in 
which  the  typical  symptoms  of  spasmodic  paralysis  were  present 
during  life.  The  autopsy  was  conducted  by  Prof.  Klob,  who 
found  symmetrical  sclerosis  of  the  posterior  portion  of  the 
lateral  columns.  Prof,  Klob,  however,  mentions  that  the 
sclerosis  extended  in  the  thoracic  and  lumbar  regions  to  the 
pia  mater,  so  that,  as  pointed  out  by  Ley  den,  the  direct  cere- 
bellar tract  must  have  been  affected,  and  the  case  cannot  be 
quoted  as  an  example  of  symmetrical  sclerosis  of  the  pyramidal 
tracts.  No  microscopic  examination  of  the  cord  was  made,  and 
this  fact  of  itself  would  render  the  case  almost  valueless  with 
respect  to  the  morbid  anatomy  of  the  affection. 

Dr.  R.  Schulz  communicates  three  cases  in  which  the 
symptoms  of  spasmodic  paralysis  were  present  during  life,  but 
in  which  the  post-mortem  examination  decided  against  a  primary 
sclerosis  of  the  pyramidal  tracts.  In  the  first  case  a  tumour  of 
the  medulla  oblongata  was  found,  accompanied  by  descending 
sclerosis  of  the  pyramidal  tracts ;  in  the  second  a  tumour  was 
found  between  the  right  lobe  of  the  cerebellum  and  pons,  but 
without  a  trace  of  descending  sclerosis;  while  the  third  case 
was  one  of  chronic  hydrocephalus  internus,  also  without  a  trace 
of  descending  sclerosis  of  the  cord. 

A  patient  under  the  care  of  Dr.  Morgan,  in  the  Manchester 
Royal  Infirmary,  who  presented  the  typical  symptoms  of  primary 
lateral  sclerosis,  died  from  some  intercurrent  disease.  The 
spinal  cord  having  been  hardened  in  bichromate  of  antmonia, 
symmetrical  sclerosis  of  the  pyramidal  tracts  of  the  lateral 
columns  of  the  cord,  from  the  medulla  oblongata  to  the  conus 
medullaris,  was  found. 

Dr.  Dreschfeld,  who  made  a  microscopic  examination  of  the 
cord,  assures  me  that  no  other  lesion  exists  in  the  cord. 
Aufrecht  has  recorded  a  somewhat  similar  case. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA. 


261 


In  the  amyotrophic  variety  of  the  affection  Charcot  has 
several  times  proved  the  presence  of  symmetrical  sclerosis  of 
the  pyramidal  tracts  of  the  lateral  columns  of  the  cord,  and  of 
the  anterior  pyramids  of  the  medulla  oblongata,  along  with 
degenerative  atrophy  of  the  anterior  grey  horns  and  loss  of  the 
large  ganglion  cells  of  the  cord  and  of  the  motor  nuclei  in  the 
medulla  oblongata.  The  condition  of  the  bulbar  nuclei  in  this 
affection  is  represented  in  Fig.  179,  borrowed  from  Charcot,  the 
diseased  nuclei  being  shown  to  the  left  of  a  fictitious  line  (R,  R'), 
and  the  healthy  one,  for  the  sake  of  comparison,  to  the  right  of 
that  line.  The  part  which  Charcot  calls  the  fasciculus  teres 
really  consists  of  a  group  of  small  cells,  and  is  the  same  as  that 
which  I  have  called  the  external  accessory  nucleus  of  the  facial. 
It  is  seen  to  be  diseased  on  the  left  side  (D')  of  the  figure.  The 
internal  accessory  facial  nucleus  is,  however,  apparently  healthy. 
These  observations  have  also  been  confirmed  by  Joffroy, 
Gomboult,  and  others.     Valuable  contributions  to  the  morbid 

Fig.  179. 


Fig.  179  (From  Charcot).  Transverse  Section  of  the  Medulla  Oblongata  on  a  level 
with  the  middle  of  the  Nucleus  of  the  Hypoglossal.— 1i,  R',  median  raphe ;  A,  B, 
represents  the  normal  condition,  and  A',  B'  the  parts  as  they  appear  in  amyo- 
trophic lateral  sclerosis ;  C,  C,  the  floor  of  the  fourth  ventricle  ;  V,  a  vessel 
which  bounds  the  nucleus  of  the  hypoglossal  anteriorly  and  externally ;  D, 
fasciculus  teres  ?  and  D',  the  corresponding  part  on  the  diseased  side  ;  A, 
healthy  nucleus  of  the  hypoglossal ;  and  A',  the  diseased  nucleus.  B,  the 
healthy  nucleus  of  the  pneumogastric  nerves  ;  and  B',  the  nucleus  on  the  dis- 
eased side,  which  is  seen  not  to  be  much  affected. 


262  SYSTEM  DISEASES   OF  THE 

anatomy  of  the  cord,  in  cases  where  the  symptoms  of  loco- 
motor ataxy  and  of  spasmodic  paralysis  were  combined,  have 
been  made  by  Westphal  and  others. 

§  461.  Morbid  Physiology. — Little  need  be  added  to  what 
has  already  been  said  with  regard  to  the  connection  which 
exists  between  the  morbid  anatomy  and  the  symptoms  in 
this  disease.  The  fibres  of  the  pyramidal  tract  convey  volun- 
tary impulses  from  the  cortex  of  the  brain  ;  and,  consequently, 
when  these  fibres  are  diseased,  and  conduction  through  them  is 
interrupted,  voluntary  paralysis  must  result.  It  is  more  difficult 
to  explain  why  voluntary  paralysis  should  be  associated  with 
muscular  tension  and  contractures,  but  I  agree  with  those 
pathologists  who  believe  that  these  symptoms  are  caused  by 
the  unantagonised  influence  of  the  cerebellum  on  the  paralysed 
muscles. 

§  462.  Diagnosis. — Spasmodic  spinal  paralysis  is  liable  to  be 
mistaken  for  transverse  myelitis,  inasmuch  as  the  lateral  columns 
are  generally  implicated  in  the  latter  disease.  In  transverse 
myelitis  there  are  various  disturbances  of  sensibility,  vesical 
weakness,  and  bed-sores,  the  paraplegia  is  developed  more  rapidly 
and  completely,  while  the  upper  boundary  of  the  paralytic 
manifestations  remains  stationary.  Reflex  action  of  the  skin  is, 
as  a  rule,  considerably  increased. 

In  the  cases  of  locomotor  ataxy  which  are  complicated  with 
sclerosis  of  the  lateral  columns,  the  diagnosis  must  largely 
depend  upon  the  history  of  the  case,  especially  with  respect  to 
the  sensory  disturbances. 

This  disease  may  be  distinguished  from  poliomyelitis 
anterior  chronica  by  the  fact  that  in  the  latter  the  paralysed 
muscles  become  rapidly  atrophied,  the  reflex  action  of  the 
tendons  and  the  faradic  excitability  of  the  muscles  are  lost,  the 
muscles  generally  manifest  the  reaction  of  degeneration,  and 
the  deformities  are  of  the  nature  of  paralytic  contractions. 

When  multiple  sclerosis  first  makes  its  appearance  in  the 
lateral  columns,  it  may  be  impossible  for  a  time  to  distinguish 
between  it  and  spasmodic  spinal  paralysis.  As  the  former 
disease  progresses,  its  symptoms  become  so  characteristic  that 
the  diagnosis  between  the  two  diseases  is  easy. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  268 

Spasmodic  spinal  paralysis  may  be  distinguislied  from 
paralyses  arising  from  lesions  of  the  cauda  equina  and  other 
peripheral  paralyses  by  the  absence  in  the  former  of  disturb- 
ances of  sensibility  and  muscular  atrophy,  the  retention  of 
electrical  excitability,  and  the  increase  of  the  reflex  action  of 
the  tendons. 

The  hemiplegic  form  of  primary  lateral  sclerosis  may  be 
mistaken  for  hemiplegia  of  cerebral  origin.  In  the  former 
disease  the  lower  extremity  is  first  affected,  and  the  paralysis 
only  advances  very  slowly  to  the  upper  extremity,  and  mus- 
cular tension  and  contractures  are  early  developed.  There  are 
no  disturbances  of  sensibility  and  no  symptoms  referable  to  the 
cerebrum  or  to  the  cranial  nerves.  A  focal  lesion  affecting  the 
pyramidal  tract  symmetrically  in  the  anterior  pyramids  of  the 
medulla  oblongata,  followed  by  descending  sclerosis,  may  cause 
symptoms  which  cannot  perhaps  be  distinguished  from  those 
of  primary  lateral  sclerosis. 

§  463.  Prognosis. — Spasmodic  spinal  paralysis  is  probably 
the  most  protracted  of  all  the  chronic  affections  of  the  spine. 
Uncomplicated  cases  do  not  appear  to  shorten  life  at  all,  owing 
to  the  entire  absence  of  disturbances  of  the  bladder,  bed-sores, 
and  any  affection  of  the  respiratory  centres.  In  some  few  cases 
the  disease  is  capable  of  considerable  improvement  or  even 
complete  recovery. 

Where  the  disease  is  complicated  with  muscular  atrophy  and 
bulbar  symptoms,  the  prognosis  is  of  course  very  grave. 

§  464.  Treatment — The  treatment  of  spasmodic  spinal  para- 
lysis is  generally  the  same  as  that  of  chronic  myelitis  and  of  tabes. 
The  galvanic  current  is  by  far  the  most  trustworthy  remedy. 
Carefully  conducted  hydropathic  treatment  may  be  beneficial, 
and  gaseous  thermal  springs  have  been  employed  with  apparent 
advantage.  The  nitrate  of  silver  has  been  used  internally,  but 
it  does  not  appear  to  be  so  useful  in  this  affection  as  in  tabes. 

The  rules  with  regard  to  diet,  exercise,  and  general  regimen 
are  the  same  as  for  other  forms  of  chronic  myelitis. 


264 


CHAPTER   V. 


II.— MIXED   DISEASES   OF   THE   SPINAL   CORD   AND 
MEDULLA  OBLONGATA. 

(I.)  PARALYSIS   ASCENDENS   ACUTA. 


Acute  Ascending  Paralysis — Landry's  Paralysis. 

§  465.  Definition. — Acute  ascending  paralysis  is  characterised 
by  a  motor  paralysis  which  generally  begins  in  the  lower  ex- 
tremities, spreads  pretty  rapidly  over  the  trunk  to  the  upper 
extremities,  and  usually  involves  the  medulla  oblongata,  the 
general  sensibility  and  also  slightly  the  functions  of  the  bladder 
and  rectum;  but  there  is  no  decided  atrophy  of  the  muscles 
and  no  alteration  of  their  electrical  excitability. 

§  466.  History. — Caaes  of  this  disease  were  described  by  Ollivier, 
Walford,  and  others,  and  it  appears  that  Cuvier  died  of  it  in  1832. 
The  disease,  however,  was  not  recognised  as  a  separate  affection  until 
1859,  when  Landry  described  some  cases  under  the  name  of  "  Paralysie 
Ascendante  Aigue."  Kussmaul  also  described  two  cases  in  the  same  year. 
Since  Landry's  publication  reports  of  cases  have  multiplied  ;  although  at 
times  instances  of  other  diseases,  such  as  of  acute  central  myelitis,  and  of 
subacute  anterior  poliomyelitis,  have  been  described  under  this  name. 

§  467.  Etiology. — Very  little  is  known  with  respect  to  the 
causation  of  this  disease ;  and  at  times  it  arises  in  the  absence 
of  recognisable  predisposing  or  exciting  causes.  Most  of  the 
reported  cases  have  occurred  between  the  ages  of  twenty  and 
forty,  and  men  are  more  frequently  attacked  than  women. 

Exposure  to  cold  is  probably  the  most  frequent  exciting  cause. 
Some  cases  have  occurred  durinsf  convalescence  from  acute 
diseases,  as  typhoid  fever,  pleurisy,  or  variola,  and  a  few  have 
followed  suppression  of  the  menses.     Various  authors  regard 


MIXED  DISEASES   OF   THE   SPINAL   CORD.  265 

syphilis  as  a  frequent  cause  of  the  disease,  but  it  is  doubtful 
how  far  this  opinion  is  correct.  In  the  case  of  a  woman  of 
twenty  years  of  age,  who  died  of  the  disease  in  the  Eoyal  In- 
firmary, within  a  week  from  the  commencement,  there  were 
deep  cicatrices  in  the  left  groin,  but  no  further  evidence  of 
syphilis  could  be  detected.  The  interior  of  the  uterus  was  lined 
with  a  layer  of  blood.  I  did  not  see  the  case  duricg  life,  but 
the  symptoms  as  reported  to  me  were  very  characteristic. 

§  468.  Sym/ptoms. — The  paralytic  phenomena  are  generally, 
though  not  always,  preceded  by  various  premonitory  symptoms, 
such  as  slight  fever,  shooting  pains  in  the  back  and  limbs, 
formication  and  numbness  in  the  feet  and  finger  tips,  and  a 
feeling  of  great  weariness,  debility,  and  general  discomfort. 
These  may  last  for  one  or  several  days,  and  they  have  occa- 
sionally existed  for  six  weeks. 

The  characteristic  symptoms  of  the  disease  now  make  their 
appearance.  Great  weakness  of  the  lower  extremities  is  soon 
complained  of,  which  increases  to  such  an  extent  as  to  render 
standing  and  walking  impossible.  The  patient  can  for  a  short 
time  execute  when  lying  down  the  individual  movements  of  the 
legs,  but  this  power  is  soon  lost.  The  paralysis  appears  first 
in  the  muscles  which  move  the  feet,  then  in  those  which  move 
the  legs,  and  at  last  in  the  muscles  of  the  thighs,  and  thus,  in 
the  course  of  a  few  days,  the  lower  extremities  may  be  com- 
pletely paralysed.  The  legs  now  lie  flaccid  and  powerless,  there 
is  no  resistance  to  passive  movements  of  them,  and  there  is 
complete  absence  of  muscular  tension  and  contractures. 

The  paralysis  advances  steadily  upwards,  the  muscles  of  the 
trunk  are  invaded,  and  sitting  up  is  rendered  impossible;  while 
the  acts  of  coughing,  sneezing,  and  defecation  are  weak  and 
ineffective  through  paralysis  of  the  abdominal  muscles. 

The  muscles  of  the  upper  extremities  are  now  attacked; 
they  are  implicated,  indeed,  before  the  abdominal  muscles,  and 
soon  become  completely  paralysed.  The  hands  first  grow 
weak,  and  finer  actions,  as  writing,  become  impossible.  The 
movements  of  the  forearm  become  more  and  more  difficult,  and 
those  of  the  shoulder-joint  are  soon  implicated,  the  arms,  like 
the  legs,  being  completely  relaxed  and  immovable. 


266  MIXED  DISEASES   OF  THE 

Disturbances  of  respiration  now  appear,  owing  to  paralysis 
of  the  intercostal  and  other  respiratory  muscles  of  the  trunk, 

The  disturbances  of  sensibility  are  quite  subordinate  to  the 
motor  paralysis,  although  they  are  not  entirely  wanting. 
Patients  frequently  complain  of  numbness  and  formication  in 
the  fingers  and  toes,  a  diminution  of  feeling  in  the  soles  of  the 
feet,  extending  occasionally  over  the  whole  of  the  lower  extre- 
mities, and  pain  may  be  complained  of  at  the  beginning  of  the 
disease,  although  it  is  never  a  prominent  symptom.  Cutaneous 
sensibility  is  usually  normal,  but  occasionally  it  is  distinctly 
lowered  towards  the  periphery  of  the  extremities,  and  in  some 
few  cases  there  is  almost  complete  ansesthesia,  while  rarely 
hyperalgesia  has  been  observed. 

A  considerable  amount  of  emaciation  may  appear  just  as  occurs 
during  the  course  of  any  other  acute  disease,  but  the  paralysed 
muscles  do  not  undergo  rapidly  progressive  atrophy,  and  the 
electrical  excitability  of  the  paralysed  nerves  and  muscles 
remains  normal.  The  nutrition  of  the  skin  is  not  aifected,  and 
bed-sores  do  not  occur. 

In  a  case  reported  by  Eisenlohr  transitory  cedema  of  the 
skin  with  redness  of  the  integument  over  various  joints  is  men- 
tioned as  having  been  present,  and  in  some  other  cases  a 
profuse  secretion  of  sweat  has  been  noticed,  but  no  other  vaso- 
motor disturbances. 

Reflex  action  is  preserved  during  the  first  few  days  of  the 
disease,  it  then  diminishes  more  or  less  rapidly,  and  is  finally 
extinguished.  In  Eisenlohr's  case  an  increase  of  reflex  action 
was  observed.  In  one  case  examined  by  Westphal  the  reflex 
excitability  of  the  tendons  was  abolished  as  well  as  that  of 
the  skin. 

The  functions  of  the  bladder  and  rectum  are  usually  un- 
affected. In  some  few  cases  slight  disturbances  of  the  bladder 
have  been  naet  with,  but  the  severe  paralysis  of  the  bladder  and 
rectum,  which  occurs  in  other  forms  of  central  myelitis,  has 
never  been  observed.     The  bowels  are  usually  constipated. 

The  general  health  is  as  a  rule  good,  and  in  the  majority  of 
cases  there  is  no  fever.  In  some,  however,  the  general  health 
is  disturbed,  and  febrile  symptoms  appear,  which  occasionally 
may  be  severe.     The  brain  is  entirely  unaffected  throughout 


SPINAL  CORD  AND  MEDULLA   OBLONGATA.  267 

the  whole  course  of  the  disease  ;  even  the  cerebral  motor  nerves 
are  not  implicated  until  the  terminal  period. 

As  the  disease  advances  upwards,  patients  complain  of  pain 
and  stiffness  in  the  neck,  and  the  muscles  of  that  region 
become  paralysed,  and  sometimes  there  is  paresis  of  the  facial 
muscles.  The  medulla  oblongata  is  soon  implicated,  and  then 
the  functions  of  articulation,  mastication,  deglutition,  and  ulti- 
mately respiration  are  interfered  with;  evidences  of  hypersemia 
and  hypostatic  congestion  of  the  lungs  appear,  and  the  patient 
dies  from  asphyxia.  Sometimes  the  pupils  have  been  unequal, 
and  the  pulse  may  become  very  frequent. 

The  duration  of  the  disease  is  somewhat  variable.  In  some 
cases  it  runs  its  course  and  ends  in  death  in  two  or  three  days, 
while  occasionally  it  lasts  from  two  to  four  weeks.  The  average 
duration  of  fatal  cases  is  from  eight  to  twelve  days. 

But  the  disease  may  end  in  recovery.  It  may  cease  to  pro- 
gress at  any  stage  of  its  development.  This  usually  takes  place 
before  the  nerves  of  the  medulla  oblongata  are  involved,  but 
recovery  has  been  known  to  take  place  even  after  disturbances 
of  respiration,  deglutition,  and  mastication  had  commenced. 

In  cases  which  run  a  favourable  course  improvement  takes 
place  at  an  early  period  of  the  disease,  the  parts  last  attacked 
by  the  paralysis  being  the  first  to  show  signs  of  improvement. 
The  patients  first  begin  to  use  their  hands,  after  a  time  they 
are  able  to  sit  up,  and  finally  after  another  considerable  interval 
they  are  able  to  stand  and  walk.  The  period  of  recovery  occu- 
pies many  weeks,  although  the  duration  varies  much  in  indi- 
vidual cases.  Fluctuations  and  relapses  may  occur  during 
recovery,  and  the  patients  complain  for  a  long  time  of  debility. 
The  disease  occasionally  begins  in  the  bulbar  nerves,  and  the 
paralysis  progresses  downwards  within  the  cord.  Cuvier,  as 
reported  by  Pellegrini-Levi,  died  of  this  acute  descending 
paralysis. 

The  following,  according  to  Landry,  is  the  order  in  which  the 
muscles  are  affected  by  paralysis : — 

1.  The  muscles  which  move  the  toes  and  foot,  then  the 
posterior  muscles  of  the  thigh  and  pelvis,  and  lastly  the 
anterior  and  internal  muscles  of  the  thigh. 


268  MIXED  DISEASES   OF   THE 

2.  The  muscles  which  move  the  fingers,  those  which  move 

the  hand,  and  the  arm  upon  the  scapula,  and  lastly  the 
muscles  which  move  the  forearm  upon  the  arm. 

3.  The  muscles  of  the  trunk, 

4.  The  muscles  of   respiration,  then  those  of   the  tongue, 

pharynx,  and  oesophagus. 

It  will  thus  be  seen  that  although  the  paralysis  pursues  a 
general  ascending  course,  yet  the  various  groups  of  muscles  are 
not  affected  in  the  same  relative  order  in  which  they  are  in- 
nervated from  the  cord.  The  muscles  of  the  hand,  for  instance, 
are  paralysed  before  those  of  the  abdomen,  yet  the  former  are 
innervated  from  the  cervical  and  the  latter  from  the  dorsal 
region  of  the  cord. 

§  469.  Diagnosis. — It  may  not  be  possible  to  arrive  at  a 
positive  diagnosis  during  the  first  days  of  the  disease,  but  when 
it  is  fully  developed  the  diagnosis  presents  no  difficulty. 

Acute  anterior  poliomyelitis  may  be  distinguished  from  this 
affection  by  the  circumstance  that  it  has  no  progressive  character, 
rarely  attacks  the  medulla,  and  hardly  ever  directly  causes  death. 
It  is  also  ushered  in  by  fever,  and  there  is  rapid  muscular 
atrophy  and  loss  of  faradic  excitability.  Even  the  temporary 
form  of  acute  anterior  myelitis  may  be  distinguished  from  acute 
ascending  paralysis  by  the  loss  of  reflex  excitability  and  lowering 
of  faradic  excitability,  and  by  the  fact  that  the  paralysis  is  not 
progressive. 

Subacute  anterior  poliomyelitis,  when  it  pursues  a  tolerably 
rapid  ascending  course,  may  very  readily  be  mistaken  for  acute 
ascending  paralysis,  but  the  latter  disease  is  not  attended  with 
muscular  atrophy,  and  electrical  excitability  is  preserved.  In 
subacute  anterior  poliomyelitis  reflex  action  is  earlier  abolished 
than  in  this  affection,  there  is  almost  entire  absence  of  dis- 
turbances of  sensibility  and  the  functions  of  the  bladder,  and 
bulbar  symptoms  only  appear  at  a  late  period,  and  the  disease 
is  never  so  rapidly  fatal. 

In  acute  central  myelitis  there  is  always  a  high  degree  of 
disturbances  of  sensibility,  reflex  action  is  early  abolished,  and, 
in  addition,  there  is  paralysis  of  the  sphincters,  fever,  acute  bed- 


SPINAL   CORD  AND  MEDULLA  OBLONGATA,  269 

sores,  a  lowering  of  faradic  excitability,  and  a  rapidly  fatal 
termination. 

The  spinal  form  of  syphilis,  when  it  assumes  the  form  of 
acute  ascending  paralysis,  may  be  distinguished  by  the  previous 
history  or  evidences  of  still  existing  syphilis,  and  by  the  results 
of  antisyphilitic  treatment. 

Acute  multiple  neuritis  may  be  distinguished  from  acute 
ascending  paralysis  by  the  severe  pains  limited  to  single  nerve- 
roots,  by  the  limitation  of  the  ansesthesia  and  paralysis,  and  by 
the  rapid  lowering  of  electrical  excitability. 

§  470.  Morbid  Anatomy. — All  the  examinations  which  have 
hitherto  been  made  have  yielded  completely,  negative  results 
both  as  regards  the  spinal  cord,  medulla  oblongata,  brain,  sym- 
pathetic nerves,  peripheral  nerve  trunks,  and  muscles.  The 
names  of  Vulpian,  Cornil  and  Ranvier,  Bernhardt,  Westphal, 
D^jerine,  and  Goetz,  who  have  conducted  the  examinations, 
sufficiently  attest  the  competency  of  the  observers.  Ddjerine 
and  Goetz  state  that  they  observed  changes  in  the  anterior 
roots  of  the  nerves.  The  altered  fibres  presented  the  ordi- 
nary characteristics  of  parenchymatous  neuritis  or  degenerative 
atrophy,  such  as  are  observed  in  the  peripheral  segment  of  a 
nerve  after  section. 

The  following  case  appears  to  me  to  have  been  an  example 
of  Landry's  paralysis;  but,  as  I  did  not  see  the  patient  during 
life,  the  diagnosis  must,  perhaps,  be  regarded  as  somewhat 
doubtful.  The  symptoms  were  reported  to  me  by  Mr. 
Wartenburg,  who  was  then  House  Surgeon  at  the  Royal 
Infirmary,  and  who  took  charge  of  the  case  in  the  absence  of 
the  House  Physician  : —  . 

Henrietta  R ,  set.  twenty-one  years,  was  admitted  into  the  Royal 

Infirmary,  under  the  care  of  Dr.  Browne,  on  January  26th,  1877,  and  died 
the  following  day.  On  admission  the  lower  extremities  were  completely 
paralysed,  and  there  was  partial  paralysis  of  the  upper  extremities.  The 
paralysis  of  the  upper  extremities  became  rapidly  more  pronounced,  the 
respiratory  muscles  were  soon  implicated,  and  the  patient  died  from 
asphyxia  about  thirty  hours  after  admission.  No  sensory  disturbances, 
oculo-pupillary  phenomena,  vesical  troubles,  or  bed-sores  were  noted.  The 
history  obtained  on  admission  was  that  the  patient  had  had  a  slight  blow 
on  the  back  of  the  neck  four  days  previously,  and  that  .she  soon  afterwards 


270 


MIXED   DISEASES  OF   THE 


became  paralysed  ia  the  lower  extremities.     There  were  no  contusions  or 
other  signs  of  injury. 

The  autopsy  was  conducted  by  me  thirty-six  hours  after  death,  and  the 
following  is  an  abstract  of  the  report :  Three  linear  and  deep  cicatrices 
are  observed  in  the  left  groin.  The  skin  over  the  sacrum  and  trochanters 
is  not  ulcerated ;  the  muscles  are  plump,  and  none  of  them  present  any 
signs  of  atrophy.  The  spinal  cord  was  somewhat  softer  than  usual  in  the 
lower  half  of  the  cervical  and  dorsal  regions,  and  in  the  lower  half  of  the 
lumbar  enlargement  and  conus  meduUaris,  the  remaining  portions  being 
normal.  The  other  morbid  appearances  noted  were  unimportant.  I  have 
repeatedly  examined  sections  of  the  spinal  cord,  and  always  found  the 
greater  portion  of  the  ganglion  cells  of  the  anterior  horns  so  beautifully 
defined  and  healthy  that  I  came  to  regard  the  cord  as  being  typically 
healthy.  I  observed  decided  pathological  changes  in  the  central  column, 
but  regarded  them  as  accidental,  or  at  least  of  no  importance  so  far  as  the 
functional  disturbances  present  during  life  were  concerned.  When,  how- 
ever, embryological  considerations  forced  upon  me  the  conclusion  that  the 
central  columns  were  endowed  with  important  functions,  my  judgment  of 
the  significance  of  the  morbid  changes  observed  in  this  cord  became 
altered.     A  section  of  the  dorsal  region  is  represented  in  Fig.  180 ;  the 


Fig.  180. 


Fig.  180  (Young).  Section  of  the  Upper  Dorsal  Region  of  the  Spinal^  Cord,  from  a 
case  of  Acute  Ascending  Paralysis. — A,  Anterior  horns;  P,  posterior  horns;  cc, 
central  canal ;  vc,  vesicular  column  of  Clarke ;  i,  internal,  al,  antero'lateral, 
pi,  postero-lateral  group  of  cells ;  ml,  the  medio-lateral  area.  The  diseased 
portion  is  represented  by  the  lightly-shaded  area  which  occupies  the  central 
grey  column  and  its  extensions  between  the  antero-lateral  and  postero-lateral 
groups,  and  between  the  internal  and  antero-lateral  groups. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA. 


271 


internal,  antero-lateral,  and  postero-lateral  groups  are  normal,  while  the 
central  column  and  medio-lateral  area  are  diseased.  A  section  of  the 
middle  of  the  cervical  enlargement  ia  represented  in  Fig.  181 ;  the  internal, 
anterior,  antero-lateral,  and  postero-lateral  groups  are  normal,  while  the 
central  column,  the  median  area,  and  the  central  group  of  ganglion  cells 
are  diseased.  The  diseased  areas  showed  granular  degeneration  of  Ger- 
lach's  nerve  network,  complete  disappearance  of  the  ganglion  cells,  increase 
of  nuclei,  and  dilatation  and  congestion  of  blood-vessels. 

Fig.  181. 


Fig.  181  (Young).  Section  of  the  middle  of  the  Cervical  Enlargement  of  the  Spinal 
Cord,  from  a  case  of  Acute  Ascending  Paralysis.—  c,  Central  group,  and  a,  anterior 
group  of  ganglion  cells ;  m,  median  area.  The  remaining  letters  indicate  the 
same  as  the  corresponding  letters  in  Fig.  180.  The  diseased  area  is  represented 
by  the_  lightly-shaded  portion  which  represents  the  central  grey  column  and  its 
extensions  into  the  median  area  (m),  between  the  antero-lateral  and  postero- 
lateral groups  of  cells,  and  round  the  central  group, 

§  471.  Morbid  Physiology. — The  pathology  of  this  affection 
is  exceedingly  obscure,  and  Westphal  considers  it  probable  that 
the  disease  is  due  to  some  intoxication,  and  a  similar  opinion 
had  been  maintained  by  Landry.  In  many  respects  this  disease 
is  like  tetanus.  Acute  ascending  paralysis  manifests  itself,  as 
its  name  implies,  by  loss  of  motor  power,  while  tetanus  is  mani- 
fested by  symptoms  of  motor  irritation,  but  both  affections 
are  similar  in  their  mode  of  invasion,  in  their  rapid  course,  and 
frequently  rapid  fatal  termination. 


272  MIXED   DISEASES   OF  THE 

§  472.  Prognosis. — The  prognosis  is  always  very  serious. 
The  more  rapid  the  ascending  course  of  the  disease,  the  earlier 
respiration  has  been  attacked,  and  the  more  pronounced  the 
signs  of  bulbar  paralysis,  the  graver  does  the  prognosis  become. 
When  once  the  progress  of  the  disease  is  arrested  and  improve- 
ment begins,  the  prognosis  becomes  more  hopeful,  but  even 
then  there  is  danger  of  a  relapse. 

§  473.  Treatment. — At  an  early  stage  of  the  affection  Chap- 
man's ice-bag  may  be  applied  to  the  spine.  The  constant 
current  has  been  employed  in  the  later  stages  of  the  cases 
which  have  terminated  favourably. 

(II.)    ACUTE   DIFFUSED   MYELITIS. 

Acute  Diffused  Inflammation  of  the  Spinal  Cord. 

§  474.  Definition. — Acute  diffused  myelitis  comprises  all  the 
affections  of  the  spinal  cord  which  are  attended  by  fever,  and 
which  lead  in  a  short  time  to  serious  functional  disturbances, 
with  the  exception  of  the  acute  system  diseases  of  the  cord, 
which  have  just  been  considered. 

§  475.  Etiology. — Many  cases  apparently  originate  spon- 
taneously without  any  recognisable  exciting  cause.  The  male  sex 
appears  to  be  more  subject  to  the  disease  than  the  female  sex. 
The  greater  number  of  cases  occurs  between  the  ages  of  ten  and 
thirty,  with  the  exception  of  infantile  spinal  paralysis.  Sexual 
excesses,  and  severe  bojiily  exertion,  act  as  predisposing  causes 
of  the  disease. 

The  most  usual  exciting  causes  of  the  affection  are  injuries 
such  as  those  produced  by  puncturing  and  cutting  instruments, 
fractures  and  luxations  of  the  vertebrae,  contusions,  slow  com- 
pression of  the  cord,  and  inflammatory  processes  transmitted 
from  neighbouring  organs.  Exposure  to  cold,  especially  when 
the  body  is  overheated,  or  after  severe  bodily  exertion,  and 
sleeping  on  the  damp  earth  or  in  snow,  are  the  most  frequent 
causes  of  the  affection. 

Acute  myelitis  is  not  unfrequently  developed  as  a  complication 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  273 

or  sequel  of  acute  diseases,  such  as  typhus,  the  acute  exanthe- 
mata, acute  rheumatism,  severe  puerperal  diseases,  and  more 
especially  of  variola. 

Myelitis,  running  a  very  rapid  course,  is  observed  with  un- 
usual frequency  amongst  syphilitic  patients.  Suppression  of 
the  menses  and  hsemorrhoidal  bleeding  play  a  more  or  less 
doubtful  role  in  the  etiology  of  the  disease. 

Violent  emotions  appear  sometimes  to  have  caused  the 
affection,  and  several  cases  are  recorded  in  which  the  first 
symptoms  of  myelitis  showed  themselves  immediately  after 
great  fright,  anxiety,  or  anger. 

Irritative  lesions  of  peripheral  organs  give  rise  to  acute 
myelitis.  A  proportion  of  the  so-called  reflex  paraplegias,  which 
are  developed  in  connection  with  diseases  of  the  digestive  and 
genito-urinary  organs,  or  the  joints,  should  be  classed  as  acute 
myelitis.  Feinberg  has  recently  succeeded  in  exciting  an  acute 
inflammation  of  the  spinal  cord  in  rabbits  by  varnishing  the 
skin,  but  the  mechanism  of  its  production  is  unknown. 

§  476»  Symptoms. — The  symptoms  of  acute  diffused  myelitis 
differ  greatly  in  each  individual  case,  so  that  it  is  difficult  to 
describe  the  generic  features  of  the  affection.  The  onset  of 
the  disease  is  very  variable.  It  is  sometimes  preceded  by 
general  malaise,  slight  pyrexia  with  or  without  a  feeling 
of  chilliness,  and  the  usual  febrile  accompaniments,  headache, 
general  depression,  aching  pains  in  the  limbs,  and  loss  of 
appetite.  In  many  cases  the  spinal  symptoms  make  their 
appearance  at  once,  disturbances  of  sensation  being  those 
which  usually  first  attract  the  attention  of  the  patient.  The 
symptoms  of  sensory  irritation  assume  the  greatest  prominence, 
but  in  some  few  cases  they  are  entirely  wanting,  and  the  vio- 
lent shooting  pains  of  meningitis  are  rarely  present.  The  pains 
of  myelitis  consist  of  neuralgic  pains  surrounding  the  trunk 
at  a  variable  height  like  a  girdle,  dragging,  tearing,  boring, 
or  burning  sensations  in  the  limbs  which  are  not  increased  by 
pressure  or  movement,  and  pain  in  the  back  extending  over  a 
more  or  less  extensive  area.  Several  of  the  spinous  processes 
are  often  tender  to  pressure.  The  tender  spot  can  sometimes 
be  best  elicited  by  passing  hot  and  cold  sponges  or  the  cathode 
s 


274  MIXED   DISEASES  OF  THE 

of  the  galvanic  current  along  the  vertebral  column.  Various 
parsesthesise  are  almost  constantly  present  in  the  disease,  the 
most  common  and  constant  of  these  being  the  sensation  of  con- 
striction, like  a  girdle,  which  is  felt  both  in  the  trunk  and  in  the 
extremities  and  joints.  Feelings  of  tension  or  swelling,  and  of 
cold  or  heat,  or  pricking  sensations  and  formication  are  experi- 
enced over  more  or  less  extensive  areas  of  skin,  especially  that  of 
the  lower  extremities.  True  hypereesthesia  is  rarely  present  in 
acute  myelitis,  and  when  it  occurs  it  is  probably  due  to  a  com- 
plication with  meningitis.  It,  however,  occurs  on  the  same 
side  as  the  motor  paralysis  in  unilateral  circumscribed  myelitis. 
As  the  disease  advances  the  feelings  of  numbness  and  furriness 
become  more  and  more  prominent,  and  these  are  soon  followed 
by  the  diffused  painful  and  vibratory  sensations  which  Charcot 
has  named  dyssesthesise,  and  which  are  produced  by  touching 
the  skin  of  circumscribed  areas,  or  of  the  entire  surface  of  one 
or  both  extremities. 

As  the  disease  advances,  the  feelings  of  numbness  and  furri- 
ness give  place  to  complete  loss  of  sensation.  The  anaesthesia 
may  be  partial,  or  may  manifest  itself  in  the  form  of  retardation 
of  sensory  conduction.  At  other  times  it  may  be  more  or  less 
diffused  and  complete,  although  the  parts  deprived  of  sensa- 
tion may  be  subject  to  severe  pains — anwsthesia  dolorosa. 
Shooting  pains  and  spasmodic  twitchings  of  the  muscles  are 
very  common  in  the  paralysed  parts.  Patients  complain  at 
times  of  painful,  dragging  sensations  in  the  bladder  and  rectum, 
gastralgie  attacks,  and  neuralgic  pains  in  the  other  viscera.  In 
all  severe  cases  there  is  complete  anaesthesia  of  the  lower  half 
of  the  body  up  to  a  certain  height,  the  anaesthetic  being  marked 
off  from  the  normal  skin  by  a  pretty  sharply  defined  line. 

The  motor  disturbances  consist  of  both  irritative  and  paralytic 
phenomena.  In  children  the  onset  of  the  disease  is  marked 
by  general  convulsions.  The  symptoms  of  motor  irritation  of 
spinal  origin  are  twitchings  of  individual  muscles  or  of  entire 
extremities,  while  at  times  the  spasmodic  contractions  of  the 
muscles  may  increase  to  a  condition  of  tetanic  rigidity.  The 
paralytic  symptoms  are,  however,  much  more  constant  and 
important.  They  may  sometimes  be  developed  with  such 
rapidity  that  we  speak  of  a^oijlectiform  myelitis.     In  some 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  275 

cases  the  paralysis  may  be  developed  in  the  course  of  a  night, 
or  even  in  less  than  an  hour,  while  in  the  heemorrhagic  form  it 
may  develop  in  the  course  of  a  few  minutes.  When  the  para- 
lytic symptoms  are  rapidly  developed  the  muscles  are  perfectly 
flaccid,  and  offer  no  resistance  to  passive  movements  of  the 
joints,  and  when  the  limbs  are  raised,  they  fall  like  those  of  a 
dead  body.  Symptoms  of  motor  irritation  may  reappear  in  the 
affected  limbs  at  a  later  period  of  the  disease,  if  the  patient 
survive.  Isolated  spontaneous  twitchings  of  the  muscles  may 
then  be  observed  in  the  paralysed  limbs,  these  being  generally 
accompanied  by  severe  shooting  pains. 

Spasmodic  tonic  contractions  of  the  muscles  occur,  which 
are  excited  by  a  voluntary  effort  to  move  the  affected  limb, 
or  by  irritation  of  the  sensitive  nerves.  Ultimately  severe 
contractures  are  produced,  which  fix  the  legs  in  an  extended  or 
flexed  position,  and  are  frequently  rendered  more  intense  by 
attempts  at  active  or  passive  movements  of  the  paralysed 
limbs.  These  symptoms  are,  however,  more  frequently  ob- 
served in  the  subacute  and  chronic  than  in  the  acute  forms  of 
myelitis. 

The  most  common  forms  of  paralysis  are  paraplegia,  hemi- 
paraplegia,  monoplegia,  and  paralysis  of  the  cervical  muscles, 
while  complete  paralysis  of  all  four  extremities  and  of  the 
greater  number  of  the  muscles  of  the  trunk  not  unfrequently 
occurs. 

The  reflex  excitability  varies  according  to  the  seat  of  the 
disease.  The  reflex  activity  of  both  the  skin  and  muscles 
may  be  diminished,  destroyed,  or  increased.  In  some  cases 
it  is  abolished  at  an  early  period  of  the  disease,  and  im- 
mediately after  the  development  of  the  paralysis,  so  that 
reflex  actions  cannot  be  excited  even  by  severe  irritants.  At 
other  times  it  is  not  entirely  abolished,  but  a  longer  time  is 
required  for  the  production  of  reflex  movements;  while  in  other 
cases  it  undergoes  a  considerable  increase,  so  that  slight  irri- 
tations call  forth  active  reflex  muscular  twitchings,  which  may 
increase  to  a  convulsive  jerking  of  the  paralysed  parts.  In 
other  cases  the  reflex  excitability  is  unaltered,  or  it  is  slightly 
increased  for  a  time  and  then  begins  to  diminish  and  gradually 
becomes  weaker,  and  finally  disappears. 


27G  MIXED  DISEASES  OF  THE 

The  sphincters  are  frequently  involved.  Vesical  paralysis  may 
be  one  of  the  earliest,  or  even  a  premonitory  symptom  of  acute 
myelitis.  In  severe  cases  complete  retention  of  urine  is  usually 
present,  so  that  the  use  of  the  catheter  is  rendered  necessary. 
In  other  cases  there  is  merely  incontinence  of  urine,  while  in 
the  beginning  the  symptoms  are  those  of  irritation,  such  as 
spasmodic  closure  of  the  sphincter,  with  increased  desire  to 
urinate.  In  severe  cases  the  urine  after  the  seventh  or  eighth  day 
becomes  alkaline  and  sometimes  bloody  ;  it  contains  numerous 
crystals  of  the  triple-phosphates,  and  there  is  a  muco-purulent 
deposit.  Paralysis  of  the  sphincter  ani  is  generally  present. 
Priapism  is  a  not  uncommon  symptom  in  acute  myelitis,  the 
erections  generally  being  incomplete,  but  often  persisting  for 
days,  with  slight  variations  in  degree. 

The  vaso-motor  disturbances  are  variable.  Engelken  found 
in  one  case  a  rise  in  the  temperature  of  the  paralysed  parts, 
but  most  authors  speak  of  the  extremities  as  being  cold. 
Diffuse  cedema  of  the  paralysed  lower  limbs  is  often  ob- 
served. The  perspiration  is  sometimes  increased,  some- 
times diminished.  The  trophic  disturbances  consist  of  gan- 
grenous inflammation  of  the  skin  over  the  sacrum,  trochanters, 
and  other  exposed  situations,  and  these  usually  progress 
rapidly  and  prove  fatal  by  septic  fever.  When  the  lesion  is 
unilateral  the  bed-sore  is  situated  on  the  opposite  side  of  the 
body  to  the  motor  paralysis.  Acute  bed-sore  may  make  its 
appearance  as  early  as  from  the  second  to  the  fifth  day  of  the 
disease. 

The  case  may  terminate  so  rapidly  that  there  is  no  time 
for  the  development  of  trophic  changes  in  the  nerves  and 
muscles,  but  traces  of  degenerative  atrophy  have  been  found 
even  in  rapidly  fatal  cases  of  central  myelitis.  The  atrophy  of 
the  muscles  is  generally  well  marked  when  the  disease  has  been 
of  somewhat  longer  duration.  In  these  cases  there  is  loss  of 
faradic  irritability  of  the  muscles  and  nerves  along  with  the 
development  of  the  reaction  of  degeneration.  There  are  cases 
of  acute  myelitis,  however,  in  which  there  is  no  change  in  the 
electric  irritability,  and  others  in  which  only  slight  quantitative 
changes  such  as  slight  increase  or  diminution  can  be  demon- 
strated. 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  277 

Cerebral  phenomena  are  not  often  present  in  acute  myelitis, 
but  in  children  there  may  be  headache,  delirium,  and  general 
convulsions  at  the  beginning.  Headache  and  delirium  some- 
times occur  in  the  adult,  but  they  are  probably  due  to  the 
accompanying  fever  or  to  the  simultaneous  presence  of  sep- 
ticEemia  or  uraemia. 

When  the  inflammatory  process  extends  to  the  brain  graver 
cerebral  symptoms  become  developed.  In  cervical  myelitis 
oculo-pupillary  symptoms  are  sometimes  observed,  and  when 
the  medulla  oblongata  is  implicated  speaking  and  swallowing 
may  be  interfered  with.  Disturbances  of  the  optic  and  ocular 
nerves,  such  as  occur  in  cases  of  locomotor  ataxia,  have  not 
been  observed. 

The  bowels  are  obstinately  constipated,  and  at  a  later  period 
the  abdomen  may  be  greatly  distended  with  flatus. 

The  pulse  is  increased  in  frequency,  and  when  the  myelitis 
extends  to  the  cervical  portion  of  the  cord  the  acceleration  of 
the  pulse  may  be  very  great.  Many  patients  suffer  from  palpi- 
tation and  irregularity  in  the  action  of  the  heart,  accompanied 
by  unpleasant  sensations  in  the  cardiac  region. 

When  the  abdominal  muscles  become  paralysed,  all  forcible 
expiratory  acts,  as  coughing,  are  rendered  feeble,  and  conse- 
quently the  air  passages  cannot  be  cleared  of  mucus.  The 
erectores  spinas  are  probably  paralysed  even  before  the  ab- 
dominal muscles. 

As  the  disease  ascends  still  further  the  intercostal  muscles 
become  paralysed,  and  the  patients  breathe  only  with  the 
diaphragm.  When  the  latter  muscle  is  involved  in  the  para- 
lysis the  dyspnoea  becomes  intense,  inspiration  being  only 
carried  on  by  means  of  the  cervical  muscles,  and  death  by 
asphyxia  is  imminent. 

The  formation  of  bed-sores  and  cystitis  cause  sleeplessness 
and  loss  of  appetite,  which  are  soon  followed  by  marked  dis- 
turbance of  nutrition,  great  emaciation,  and  exhaustion. 

Fever  is  generally  present  in  the  commencement  of  acute 
myelitis.  It  may  at  times  run  very  high  and  remain  per- 
sistently high  throughout  the  entire  course  of  the  disease.  At 
other  times  it  occurs  in  isolated  sharp  attacks,  and  an  excessive 
rise  of  temperature  is  not  unfrequently  observed  immediately 


278  MIXED  DISEASES  OF  THE 

before  death.  In  other  cases  the  fever  is  slight,  never  attains 
a  high  grade,  and  may  disappear  entirely  during  the  subsequent 
course  of  the  disease.  An  exhaustive  symptomatic  fever  occurs 
in  the  latter  stages  of  the  affection,  caused  by  the  bed-sores, 
cystitis,  pyelo-nephritis,  and  consequent  septic  infection. 

§  477.  Course,  Terminations,  and  Duration. — The  course 
of  acute  myelitis  is  exceedingly  variable,  but  it  is  always 
rapidly  developed,  and  it  is  this  feature  which  entitles  it  to  be 
regarded  as  an  acute  affection.  Cases  which  take  more  than 
ten  days  to  develop  may  be  regarded  as  subacute.  The 
paralysis  may  at  times  be  developed  in  an  apoplectiform  manner 
almost  without  premonitory  symptoms,  and  it  may  attain  con- 
siderable intensity  in  an  hour  or  even  less.  As  a  rule,  however, 
there  is  a  premonitory  stage  of  variable  length,  and  days  may 
elapse  before  the  paralysis  develops  into  pronounced  paraplegia. 
At  times  the  development  of  the  disease  is  interrupted  by 
remissions  instead  of  being  continuous. 

In  central  myelitis  and  hsematomyelitis  the  paralysis  rapidly 
ascends,  symptoms  of  asphyxia  appear,  and  death  takes  place 
in  a  few  days ;  or  the  fatal  termination  is  brought  about  by  the 
violent  fever  and  septicaemia  caused  by  the  acute  bed-sores  and 
cystitis,  and  life  may  then  be  prolonged  for  a  period  of  a  few 
weeks.  In  the  less  severe  cases,  particularly  when  the  entire 
lumbar  enlargement  is  affected  with  or  without  the  dorsal  por- 
tion of  the  cord,  the  course  is  somewhat  slower.  There  is  com- 
plete paraplegia  with  paralysis  of  the  bladder,  cystitis,  decubitus, 
fever,  cachexia,  and  exhaustion,  and  the  patient  succumbs  after 
several  weeks  or  months. 

In  all  other  cases  chronic  myelitis  is  developed,  and  the 
symptoms  are  then  complete  motor  paralysis  with  incomplete 
paralysis  of  sensation  and  of  the  bladder.  The  symptoms 
may  then  remain  stationary  for  months  or  years.  After  the 
disease  has  persisted  for  a  variable  time  cystitis  and  bed-sores 
may  develop,  but  they  never  become  very  severe  and  are 
susceptible  of  being  at  least  partly  cured.  Death  finally  results 
from  exhaustion  or  from  some  intercurrent  disease. 

In  other  cases  the  disease  ceases  and  the  general  health  is 
soon  completely  restored.     The  disorders  of  sensation  and  of 


SPINAL  CORD  AND   MEDULLA  OBLONGATA.  279 

the  bladder,  and  the  trophic  disorders  of  the  skin,  are  usually 
entirely  wanting.  The  disease  then  terminates  in  imperfect 
recovery,  the  only  traces  left  being  paralysis  and  atrophy  of 
one  or  more  muscular  groups. 

Complete  recovery  takes  place  in  rare  cases, ,  and  in  these 
symptoms  of  improvement  set  in  early.  After  paralysis,  fever, 
and  other  symptoms  of  a  mild  attack  of  acute  myelitis  have 
persisted  for  one  or  two  weeks  they  undergo  a  slow  and  gradual 
retrogression,  and  in  a  few  weeks  all  the  functions  of  the  body 
are  completely  restored,  although  convalescence  is  somewhat 
protracted, 

§  478.  Morbid  Anatomy. — After  acute  inflammation  the 
spinal  cord  is  generally  softened,  but  the  appearances  presented 
by  the  diseased  parts  differ  according  to  the  stage  of  the  mye- 
litis. Leyden  divides  the  inflammatory  softenings  of  the  spinal 
cord  into  (1)  red,  (2)  yellow,  (3)  white,  (4)  grey,  and  (5)  green 
or  purulent  softening. 

(1)  Red  Softening. — The  stage  of  hyperaemia  and  com- 
mencing exudation  is  not  often  met  with  post  mortem.  It 
may,  however,  be  observed  in  cases  of  traumatic  and  central 
myelitis  which  run  a  rapidly  fatal  course.  The  affected  spot 
ma^  be  found  swollen,  the  transverse  markings  on  section 
being  blurred  and  indistinct,  and  the  cut  surface  presenting  a 
variegated  marbled  appearance.  The  colour  may  vary  from  a 
rosy  injection  to  a  deep  red,  reddish  brown,  or  chocolate  colour, 
and  numerous  capillary  hgeraorrhages  may  be  observed.  The 
inflamed  spots  are  moist  and  soft,  and  swell  up  above  the  level 
of  the  cut  surface,  and  at  times  the  tissue  becomes  diffluent. 
In  rare  instances  a  slight  increase  of  consistency  is  observed  in 
the  stage  of  hypergemia.  The  membranes  in  the  neighbourhood 
of  the  affected  spot  also  frequently  present  the  signs  of  hyper- 
semia  and  inflammation. 

(2)  Yellow  Softening. — As  the  disease  progresses  the  affected 
parts  become  paler  and  softer,  hence  this  stage  may  be  called 
that  of  yellow  softening.  The  change  of  colour  from  red  to 
yellow  is  due  partly  to  the  diffusion  and  alteration  of  the 
colouring  matter  of  the  blood,  and  partly  to  the  fatty  degene- 
ration of  the  medullary  sheaths,  and  the  formation  of  masses 
of  fat-granules. 


280  MIXED  DISEASES   OF  THE 

(3)  White  Softening. — Owing  to  the  continued  process  of 
fatty  degeneration  the  colour  becomes  progressively  whiter,  and 
the  diseased  portions  assume  a  creamy  or  milky  appearance. 
The  medulla  now  swells  up  above  the  cut  surface,  and  assumes 
a  pulpy  or  even  fluid  consistence,  and  often  flows  out  of  the 
sac  of  the  pia  mater.  After  a  time  nothing  remains  of  the 
inflamed  spot  but  the  vascular  network,  and  a  portion  of  the 
hypertrophied  septa,  between  which  a  softened  mass  is  held 
that  can  be  readily  pressed  out. 

(4)  Grey  Softening. — In  consequence  of  the  absorption  of 
the  fat-granules  and  nerve-substance,  the  affected  spot  gra- 
dually assumes  a  greyish  colour,  and  finally  becomes  smaller 
and  depressed, 

(5)  Green  Softening. — Suppuration  is  exceedingly  rare  in 
acute  myelitis,  but  occurs  sometimes  as  a  secondary  result  of 
severe  traumatic  inflammation  of  the  cord  and  its  membranes. 

§  479.  Terminations. — Grey  softening  leads  to  the  formation 
of  (1)  cicatrices,  (2)  cysts,  or  (3)  sclerosis. 

(1)  Cicatrices. — The  absorption  of  the  softened  masses  con- 
tinues until  all  the  fluid  portions  have  completely  disappeared. 
Nothing  remains  but  the  vascular  and  connective  tissue  net- 
work, which  are  in  part  thickened  and  hypertrophied.  They 
form  a  more  or  less  dense,  shrivelled,  greyish,  semi-transparent 
cicatrix,  which  is  often  pigmented.  Partial  restoration  of  the 
nerve  tissues  may  occasionally  take  place.  After  a  certain 
time,  small,  dark-bordered,  regenerated  nerve  fibres  may  be 
observed  in  the  cicatrix. 

(2)  Cysts. — More  or  less  extensive  collections  of  fluid  may 
be  left  behind  in  the  meshes  of  the  cicatrix,  and  lead  to  the 
formation  of  single  or  multiple  cysts.  They  usually  contain 
a  muddy  fluid  resembling  milk,  or  more  frequently  serum. 

(3)  Sclerosis. — In  some  cases  the  interstitial  tissue  becomes 
hypertrophied  and  consolidated.  It  increases  in  thickness  and 
density ;  the  vessels  become  larger,  and  their  walls  thicker ; 
the  previously  softened  spot  becomes  firmer  and  denser,  grey 
and  semi-transparent,  and  presents  a  marked  contrast  in  colour 
aud  consistency  with  the  surrounding  parts.    This  process  leads 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  281 

to  hardening  or  sclerosis.  The  cases  in  which  sclerosis  occurs 
have  assumed  the  chronic  form. 

The  meninges  are  always  implicated,  the  inflammatory  process 
giving  rise  to  cloudiness  of  the  membranes,  infiltration  with 
serum,  cellular  elements,  or  pus,  thickening,  adhesions,  and 
capillary  extravasations.  The  spinal  fluid  is  usually  increased, 
and  sometimes  becomes  cloudy  and  reddish,  but  it  may  remain 
unchanged. 

The  condition  of  the  roots  of  the  nerves  is  regulated  by  that 
of  the  pia  mater,  and  they  are  sometimes  softened  and  swollen, 
sometimes  atrophic,  grey,  translucent,  and  indurated. 

In  the  later  stage  ascending  sclerosis  is  found  in  the  columns 
of  Goll  and  direct  cerebellar  tracts,  and  descending  sclerosis  in 
the  pyramidal  tract. 

§  480.  Microscopical  Examination. — The  changes  observed 
on  microscopical  examination  are  those  of  (1)  the  blood-vessels, 
(2)  the  neuroglia,  (3)  the  nerve  fibres,  and  (4)  the  ganglion  cells. 

(1)  The  Blood-vessels. — In  the  first  stage  there  is  marked 
dilatation  of  the  capillaries  and  small  arteries  and  more  especially 
of  the  small  veins.  They  are  distended  with  blood,  and  not 
unfrequently  enveloped  in  layers  of  white  and  red  blood  cor- 
puscles arranged  in  the  form  of  a  sheath.  The  walls  of  the 
vessels  are  thickened  and  studded  with  fat-granules  and 
granule-cells,  while  the  lymph  sheaths  are  filled  by  a  granular 
or  cellular  exudation.  Colloid  and  hyaline  exudations  have 
been  described  but  these  are  probably  produced  by  imperfect 
methods  of  hardening. 

(2)  The  Neuroglia. — Marked  changes  are  found  in  the  neu- 
roglia. The  fibres  of  the  reticulum  are  thickened  and  swollen, 
the  network  is  much  denser  and  more  distinct,  and  in  part 
filled  with  nuclei  and  cells.  The  glia  cells  themselves  are 
swollen  and  increased  in  number,  and  often  contain  several 
nuclei.  Granule-cells,  in  greater  or  less  number,  are  found 
either  in  the  immediate  neighbourhood  of  the  vessels,  or  scattered 
irregularly  in  the  interstitial  tissue  and  its  meshes. 

(3)  The  Nerve  Fibres. — The  nerve  fibres  present  irregular 
contractions  and  enlargements;  the  medullary  sheath  has  in 
places  broken  down  into  globules  or  larger  irregular  fragments, 


282  MIXED   DISEASES   OF  THE 

which  undergo  a  granular  degeneration  and  are  finally  absorbed. 
The  axis  cylinders  are  swollen,  often  attaining  enormous  dimen- 
sions. They  present  large  spindle-shaped  swellings,  appear 
cloudy,  and  are  in  a  state  of  granular  degeneration. 

In  the  second  stage  the  nerve  fibres  are  broken  down  into 
fragments,  the  medullary  sheath  is  in  a  state  of  fatty  degenera- 
tion, and  the  axis  cylinders  altered  or  destroyed, 

(4)  The  Ganglion  Cells. — The  nerve  cells  are  involved  in  the 
inflammatory  changes.  They  are  swollen,  often  to  a  consider- 
able size,  their  substance  is  clouded,  and  the  nucleus  and 
nucleolus  may  at  times  be  observed  in  process  of  division, 
while  at  other  times  they  undergo  vacuolation.  Their  processes 
are  also  swollen,  cloudy,  irregular  in  shape,  and  in  part  destroyed. 
At  a  later  period  the  cells  shrivel,  lose  their  processes,  and  become 
reduced  to  small  angular  masses  without  structure,  while  some 
may  entirely  disappear. 

When  a  cicatrix  has  formed,  the  affected  spot  is  occupied  by 
a  dense  connective  tissue  containing  numerous  nuclei  and  neu- 
roglia cells ;  numerous  Deiter's  cells  may  be  observed,  and  they 
are  often  large  and  possess  numerous  processes.  The  vessels 
are  dilated,  their  walls  are  thickened,  and  the  ganglion  cells,  if 
any  remain,  are  atrophic.  When  cysts  are  formed  they  are  sur- 
rounded by  a  more  or  less  dense  layer  of  connective  tissue,  and 
they  are  generally  traversed  by  a  loose  connective  tissue  net- 
work. Nothing  can  be  detected  in  the  fluid  except  detritus. 
When  the  case  has  become  chronic  and  sclerosis  has  occurred, 
the  increase  of  the  interstitial  tissue  becomes  particularly  dis- 
tinct. This  condition  will,  however,  be  described  under  chronic 
myelitis.  The  'peripheral  nerves  have  been  found  in  different 
stages  of  degenerative  atrophy,  more  especially  in  central  mye- 
litis. The  muscles  also  manifest  the  characteristic  appearances 
of  the  first  stage  of  atrophy. 

The  mucous  membrane  of  the  bladder  is  often  found  swollen 
and  covered  with  mucus.  Hsemorrhagic  spots  are  frequently 
observed  in  it,  or  it  may  present  sloughs,  or  be  covered  with 
diphtheritic  exudation.  Similar  changes  are  often  found  in  the 
ureter,  extending  to  the  pelvis  of  the  kidney.  The  kidneys  are 
filled  with  metastatic  abscesses.  The  lungs  are  frequently  con- 
gested, and  often  present  the  appearances  which  characterise 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  283 

pneumonia;  the  pleurae  and  pericardium  are  generally  studded 
with  small  hgemorrhagic  spots. 

The  large  sloughs  characteristic  of  acute  bed-sores  are  usually- 
found  on  the  parts  exposed  to  mechanical  pressure,  as  the 
sacrum,  nates,  and  trochanters. 

§  481.  Morbid  Physiology. — The  initial  symptoms  of  irrita- 
tion must  be  ascribed  to  the  increase  of  the  irritability  of  the 
nerve  cells  and  fibres,  caused  by  increased  nutritive  activity 
during  the  early  stages  of  the  inflammatory  process,  and  the 
later  symptoms  of  paralysis  to  the  destruction  of  these  elements 
and  their  compression  by  the  inflammatory  exudation.  The 
girdle  pains  depend  upon  implication  of  the  posterior  roots  in 
the  inflamed  focus,  and  the  parassthesise  and  neuralgic  pains  of 
the  inferior  half  of  the  body  by  irritation  of  the  sensory  tracts 
situated  in  the  grey  substance  and  in  the  posterior  white 
columns  of  the  cord.  Since  the  sensory  tracts  either  lie  within 
the  grey  substance  or  pass  through  it  for  a  certain  distance  the 
intense  anaesthesia  in  acute  central  myelitis  may  be  readily 
accounted  for.  In  the  circumscribed,  disseminated,  and  cortical 
forms  of  myelitis,  the  degree  of  disturbance  of  sensation  will 
depeud  solely  on  the  extent  to  which  the  posterior  roots  and 
sensory  tracts  are  involved  in  pathological  changes. 

The  motor  disturbances  are  first  caused  by  irritation  and 
subsequently  by  loss  of  function  of  the  motor  centres  and  con- 
ducting fibres  in  the  cord.  When  the  anterior  horns  of  grey 
matter  are  affected,  paralysis  ensues  with  complete  flaccidity  of 
the  limbs.  When  the  pyramidal  tract  is  affected,  loss  of  volun- 
tary power  ensues,  followed,  if  the  patient  survive  some  weeks, 
by  muscular  tension  and  contractures. 

The  condition  of  the  reflex  excitability  furnishes  a  valuable 
indication  of  the  state  of  the  ^  grey  substance.  So  long  as  the 
grey  substance  is  unaffected,  so  long  is  there  a  continuance  of 
reflex  actions,  unless  indeed  the  reflex  arcs  be  interrupted  in 
their  passage  through  the  posterior  and  anterior  roots  and  their 
continuations  through  the  white  columns  to  reach  the  grey 
substance.  When  a  portion  of  the  grey  substance  is  separated 
from  its  connection  with  the  brain  by  a  myelitis  situated  higher 
up  the  cord,  reflex  actions   become  increased.     In  transverse 


284  MIXED  DISEASES  OF   THE 

myelitis  of  the  dorsal  region,  the  lumbar  portion  of  the  grey 
matter  is  separated  from  the  brain,  but  being  itself  healthy 
the  reflex  of  the  sole  is  increased.  When  the  disease  is  situated 
in  the  cervical  region,  the  cremasteric,  gluteal,  abdominal,  epi- 
gastric, dorsal,  and  scapular  reflexes  are  increased.  When 
the  grey  substance  is  destroyed  by  disease,  the  reflexes  are 
abolished,  hence  their  disappearance  in  myelitis  of  the  lumbar 
enlargement,  and  more  especially  in  diffuse  central  myelitis, 
in  which  all  reflex  action  is  usually  abolished  from  the  very 
commencement.  When  inflammation  gradually  extends  down- 
wards, the  reflex  activity,  which  may  have  been  normal  or 
increased  at  first,  subsequently  becomes  weaker  and  gradu- 
ally disappears.  Important  conclusions  can  be  drawn  from  the 
condition  of  the  reflex  excitability  with  regard  to  the  localisation 
of  the  myelitis  in  the  grey  substance.  The  reflex  actions  can 
also  be  modified  by  disease  of  the  anterior  roots,  and  disease  of 
the  lateral  columns  appears  also  to  exert  an  important  influence 
on  them,  especially  on  the  tendon  reflexes. 

When  the  myelitis  affects  the  lumbar  region,  the  sphincters 
of  the  bladder  and  rectum  become  involved,  beginning  with 
spasmodic  closure  of  them  and  ending  in  paralysis.  The  priapism 
which  is  so  often  present  must  be  regarded  as  a  sign  of  irritation 
produced  either  by  irritation  of  the  nerve  tracts  passing  from 
the  brain  to  the  lumbar  portion  of  the  cord,  or  by  leflex  excita- 
tions proceeding  from  the  bladder  or  skin. 

The  trophic  affections  of  the  muscles  and  bones  are  caused 
by  lesion  of  the  ganglion  cells  of  the  anterior  horns,  while  the 
cutaneous  trophic  affections  and  bed-sores  appear  to  be  caused 
by  disease  of  the  posterior  horns.  The  vaso-motor  disturbances 
are  caused  by  interference  with  the  vaso-motor  centres  of  the 
cord,  but  the  mechanisms  in  the  cord  which  preside  over  these 
functions  are  not  yet  clearly  ascertained. 

§  482.   Varieties  of  Acute  Diffused  Myelitis. 

The  following  forms  of  acute  diffused  myelitis  may  be  distin- 
guished : — 1,  Acute  central  myelitis;  2,  Hyper-acute  central 
myelitis  or  hsBmatomyelitis  ;  3,  Acute  bulbar  myelitis  ;  4,  Acute 
transverse  myelitis;  5,  Acute  hemilateral  myelitis;  6,  Acute 
myelo-meningitis ;  7,  Acute  disseminated  myelitis. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  285 

1.  Acute  Central  Myelitis. — This  affection  begins  suddenly  by  disturb- 
ances of  sensation,  which  are  soon  followed,  often  in  the  course  of  a  few 
hours,  by  complete  ansesthesia  and  paralysis  of  the  lower  extremities,  with 
flaccidity  of  the  limbs,  and  paralysis  of  the  bladder  and  rectum.  The 
reflex  excitability  is  abolished,  and  the  paralysed  muscles  undergo  early 
and  rapid  atrophy,  with  loss  of  faradic  contractility.  The  further  progress 
of  the  disease  is  marked  by  acute  bed-sores,  cystitis,  and  ammoniacal  urine, 
oedema  of  the  paralysed  limbs,  arthropathies,  more  or  less  intense  fever, 
progressive  advance  of  the  paralysis  upwards,  and  early  death  by  asphyxia. 

Morbid  Anatomy. — In  this  form  of  myelitis  the  softening  affects  prin- 
cipally the  grey  substance,  which  often  flows  out  or  becomes  depressed 
under  the  surface  of  section  when  the  cord  is  divided  transversely.  On 
microscopic  examination  the  disease  is  seen  to  extend  in  the  lumbar  region 
forwards  from  the  central  column  into  the  anterior  grey  horns,  the  gan- 
glion cells  of  which  may  be  entirely  destroyed,  and  also  backwards  into 
the  posterior  grey  horns.  In  the  cervical  and  upper  dorsal  regions  of 
the  cord  and  in  the  medulla  oblongata,  however,  the  disease  is  restricted 
to  the  central  grey  columns,  and  the  accessory  cells  of  the  anterior  horns 
and  their  continuations  through  the  medulla,  while  the  fundamental  cells 
in  these  regions  may  be  almost  entirely  unaffected. 

2.  Hcematomyelitis  is  a  variety  of  acute  central  myelitis,  and  is  distin- 
tinguished  from  the  latter  clinically  only  by  the  sudden  onset  of  the 
symptoms.  In  hsematomyelitis  the  paralysis  becomes  complete  in  the 
course  of  a  few  minutes,  or  at  most  in  the  course  of  an  hour  or  two,  and 
the  more  rapid  is  the  development  of  the  disease  the  more  predominant 
is  the  hsemorrhagic  element  in  the  morbid  process  likely  to  be.  Hsemato- 
myelitis can  only  be  distinguished  from  haemorrhage  into  the  substance 
of  the  cord  in  those  cases  in  which  the  paralytic  symptoms  are  preceded 
by  parsesthesise,  girdle  sensations,  vesical  weakness,  muscular  twitchings, 
and  fever. 

Morbid  Anatomy. — The  morbid  anatomy  is  the  same  as  that  of  acute 
central  myelitis,  except  that  in  hsematomyelitis  the  central  softened  mass 
assumes  a  hsemorrhagic  character. 

3.  Acute  Bulbar  Myelitis. — This  disease  always  begins  suddenly  by 
violent  headache,  giddiness,  vomiting,  distressing  hiccough,  various  parses- 
thesise,  difficulty  in  swallowing  and  speaking.  Consciousness  is,  however, 
preserved  contrary  to  what  occurs  in  an  apoplectic  attack.  After  a  short 
time  severe  symptoms  of  bulbar  paralysis  make  their  appearance.  The 
degree  in  which  the  inferior  muscles  of  the  face,  the  muscles  of  the  tongue 
and  soft  palate,  and  those  of  deglutition  are  affected  varies  greatly  in 
different  cases.  Disturbances  of  respiration  appear  at  an  early  period  of 
the  disease.  The  respirations  are  hurried  and  irregular,  and  there  may  be 
an  intense  feeling  of  oppression,  dyspnoea,  and  cyanosis.  The  pulse  is 
small,  quick,  and  irregular,  or  intermittent.    When  the  anterior  pyramids 


286  MIXED  DISEASES   OF  THE 

are  affected,  one,  two,  or  all  four  extremities  may  be  paralysed,  or  there 
may  be  complete  absence  of  paralysis  of  the  limbs.  The  patient  may 
complain  of  pains  and  formication  in  the  limbs,  but  there  is  no  ausesthesia. 
The  bladder  and  rectum  may  become  paralysed  towards  the  terminal 
period  of  the  disease.  The  disturbances  of  circulation  and  respiration  in- 
crease, the  patient  becomes  unconscious,  and  death  results  from  asphyxia. 
Morbid  Anatomy. — In  three  cases  of  acute  bulbar  myelitis,  observed 
by  Leyden,  small  centres  of  softening  without  definite  boundaries  were 
found  in  the  medulla  oblongata.  In  two  cases  the  centres  of  softening 
occupied  the  internal  portion  of  the  medulla  from  the  floor  of  the  fourth 
ventricle  to  the  anterior  pyramids ;  while  in  the  third  a  small  centre  of 
softening  was  found  situated  between  the  restiform  and  olivary  bodies, 
and  roots  of  the  hypoglossal  nerve. 

4.  Acute  Transverse  Myelitis. — This  variety  of  acute  inflammation  of 
the  cord  is  represented  by  the  form  of  the  disease  which  develops  after 
severe  injuries  of  the  spinal  cord  and  vertebral  column.  The  symptoms 
vary  greatly  according  to  the  level  at  which  the  cord  is  diseased.  For 
practical  purposes  acute  transverse  myelitis  may  be  subdivided  into : 
(a)  Acute  dorso-lumbar  transverse  myelitis ;  (6)  Acute  dorsal  transverse 
myelitis ;  and  (c)  Acute  cervical  transverse  myelitis. 

(a)  Acute  Dorso-lumhar  Transverse  Myelitis. — This  variety  usually 
begins  by  fever,  formication,  numbness,  and  pain  in  the  lower  extremities. 
These  symptoms  are  accompanied  or  soon  followed  by  startings  of  the 
limbs,  but  the  phenomena  of  sensory  and  motor  irritation  soon  give  place 
to  those  of  paralysis.  The  paralysed  limbs  are,  rigid,  and  the  reflexes 
both  cutaneous  and  deep,  are  exaggerated,  and  there  is  a  tonic  spasm  of 
the  sphincters.  After  a  time  the  urine  becomes  altered,  acute  bed-sores 
appear  over  the  sacrum  and  trochanters,  intermittent  fever  supervenes, 
and  the  patient  dies  from  marasmus. 

Sometimes  the  onset  and  progress  of  the  disease  is  so  rapid  that  it 
deserves  to  be  called  hyper-acute  or  apoplectiform,  flayem  has  reported 
two  cases,  in  which  death  occurred  in  the  one  in  five  days,  and  in  the 
other  in  twelve. 

(6)  Acute  Dorsal  Transverse  Myelitis. — This  form  of  the  disease  is  the 
least  dangerous  of  the  three.  The  sensory  and  motor  disturbances  are 
more  or  less  similar  to  those  which  occur  in  the  dorso-lumbar  form.  In 
acute  dorsal  transverse  myelitis,  however,  there  is  complete  absence  of 
bed-sores,  the  bladder  is  unaffected,  and  consequently  the  septicaemia  and 
marasmus  are  absent.  Cases  of  this  kind  may  completely  recover,  but, 
as  a  rule,  the  affection  assumes  the  chronic  form.  A  large  number  of 
cases  of  chronic  paraplegia  belong  to  this  variety. 

The  patient  may  at  times  recover  from  a  first  attack,  and  may  even 
partially  recover  from  a  second  and  third  attack,  and  ultimately  succumb 
to  the  disease  many  months  after  the  first  attack  (Pierret). 

(c)  Acute   Cervical  Transverse  Myelitis. — This  form  of  the  affection 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  287 

generally  begins  with  pain  in  the  back  of  the  neck,  followed  by  spasmodic 
rigidity  of  the  muscles  of  the  back  of  the  neck,  which  may  at  times  be 
more  pronounced  on  one  side,  so  that  the  head  is  rotated  as  well  as 
retracted.  The  pain  and  spasmodic  contractions  soon  extend  to  the  upper 
extremities,  and  these  symptoms  are  succeeded  by  paralysis,  muscular 
atrophy,  and  various  other  trophic  disturbances,  such  as  oidema  and 
arthropathies.  The  hands  assume  characteristic  positions,  but  these  will 
be  subsequently  described  when  we  come  to  speak  of  the  chronic  varieties 
of  the  disease.  The  lower  extremities  become  implicated  after  a  time,  and 
if  the  case  do  not  terminate  fatally  in  a  brief  space  of  time,  the  muscles 
become  the  subjects  of  contractions,  and  the  deep  reflexes  are  exaggerated. 
The  pupils  are  in  some  cases  contracted,  in  others  dilated,  and  there  may 
be  great  pallor  or  flushing  of  the  face,  but  in  other  cases  oculo-pupillary 
and  vaso-motor  phenomena  have  been  absent. 

The  paralytic  phenomena  may  be  preceded  for  some  time  by  anomalous 
symptoms,  such  as  coughs,  dyspnoea,  sweats,  wasting,  pains  between  the 
shoulders,  severe  attacks  of  vomiting  recurring  at  regular  intervals,  diffi- 
culty of  deglutition,  hiccough,  and  great  slowness  of  the  pulse,  which  may 
fall  to  twenty-eight  beats  (Gull),  or  even  ta  fifteen  beats  per  minute 
(Eulenburg).  The  inflammatory  process  generally  ascends  to  the  medulla, 
and  death  results  from  arrest  of  respiration. 

Morbid  Anatomy. — Little  need  be  said  with  regard  to  the  morbid 
appearances  presented  in  cases  of  acute  transverse  myelitis.  The  main 
centre  of  the  lesion  is  found  in  various  stages  of  softening,  and  the  cord 
may  be  so  diffluent  that  the  softened  mass  flows  out  on  section.  If  the 
case  has  assumed  a  more  or  less  chronic  form,  the  usual  ascending  and 
descending  degenerations  are  observed  above  and  below  the  primary  seat  of 
disease. 

In  cases  which  are  rapidly  fatal  there  is  no  time  for  the  secondary 
degenerations  to  occur ;  but  I  have  always  observed  that  the  central  grey 
substance  is  afiected  both  above  and  below  the  primary  lesion.  In  the 
neighbourhood  of  the  primary  lesion  all  the  ganglion  cells  of  the  anterior 
horns  may  be  destroyed;  but  in  the  portions  of  the  cord  remote  from 
the  latter,  the  disease  of  the  grey  substance  becomes  more  and  more 
limited  to  the  central  grey  column,  and  the  margins  of  the  groups  of 
the  ganglion  cells  of  the  anterior  horns.  Although  Fig.  146  has  been 
taken  from  a  somewhat  protracted  case  of  myelitis,  I  have  observed 
similar  appearances  in  the  cervical  region  of  the  cord  from  a  case  of 
fracture  of  the  vertebral  column  in  the  dorsal  region,  which  proved  fatal 
in  five  days.  The  continuation  of  the  central  column  upwards  into  the 
medulla,  and  the  accessory  nuclei  of  the  latter,  are  generally  implicated. 

5.  Acute  Hemilateral  Myelitis. — When  the  lesion  is  limited  to  one-half 
of  the  cord  there  are  motor  paralysis,  hypersesthesia,  and  elevation  of 
temperature  on  the  side  of  the  lesion,  and  more  or  less  aneesthesia  on  the 
opposite  side.  The  symptoms  and  morbid  anatomy  of  this  affection  will 
be  more  fully  described  hereafter. 


288  MIXED  DISEASES   OF  THE 

6.  Acute  My elo- Meningitis. — Acute  myelitis  is  frequently  complicated 
with  meningitis.  We  shall  hereafter  speak  of  those  cases  in  which 
myelitis  is  developed  simultaneously  with  or  as  a  complication  of  acute 
meningitis,  but  at  present  we  wish  to  limit  our  remarks  to  the  cases  in 
which  meningeal  changes  are  superadded  to  acute  myelitis.  This  compli- 
cation is  not  very  important,  since  the  addition  of  meningitis  to  an  acute 
inflammatory  affection  of  the  cord  does  not  appear  to  add  to  the  gravity 
of  the  latter.  The  symptoms  which  indicate  meningitis  are  pain  and  stiff- 
ness in  the  back  and  neck,  pronounced  hypersesthesia,  and  diffused  pains. 
When  these  symptoms  are  superadded  to  those  of  acute  myelitis,  the  case 
is  likely  to  be  one  of  myelo-meningitis. 

Morbid  Anatomy. — When  the  membranes  are  affected  they  become 
congested,  and  sometimes  capillary  extravasations  may  be  observed  in 
them,  or  they  are  infiltrated  with  serum  and  cellular  elements,  the  spinal 
fluid  is  increased  in  quantity,  is  cloudy  or  reddish,  and  in  more  protracted 
cases  the  membranes  become  thickened  and  loosely  adherent.  On  micro- 
scopical examination  the  membranes  are  found  thickened  and  infiltrated 
with  cellular  elements,  while  in  the  cortical  layer  of  the  spinal  cord  itself 
a  large  number  of  the  nerve  fibres  are  destroyed,  the  connective  tissue 
septa  being  thickened,  and  a  great  increase  in  the  number  of  Deiter's  cells 
having  taken  place.  In  carmine  preparations,  after  hardening,  the  cord 
is  surrounded  by  a  highly-stained  border  which  extends  into  the  substance 
of  the  cord  to  a  greater  or  lesser  depth,  according  to  the  extent  of  the 
disease.  This  form  of  disease  has  consequently  been  called  peripheric  or 
cortical  myelitis. 

7.  Acute  Disseminated  Myelitis. — The  symptoms  of  this  affection  are 
paraplegia,  sometimes  associated  with  spastic  symptoms.  The  bladder 
is  generally  paralysed.  The  state  of  the  sensibility  is  variable,  but  it  is 
generally  more  or  less  impaired.  The  reflex  and  electric  excitability  is 
also  variable,  both  being  generally  diminished.  The  grouping  of  the 
symptoms  and  the  exacerbations  show  sometimes  during*  life  that  several 
centres  of  disease  exist.  The  disease  may  be  suspected  if  the  symptoms 
of  acute  myelitis  supervene  during  an  attack  of  variola,  or  if  they  develop 
suddenly  in  phthisical  patients. 

Morbid  Anatomy. — This  form  of  myelitis  occurs  in  small  spots  scattered 
through  the  substance  of  the  cord,  and  appears  to  form  an  intermediate 
grade  between  the  acute  and  chronic  forms  of  myelitis.  The  essential 
characteristic  of  the  morbid  process  appears  to  be  an  increase  in  the  inter- 
stitial tissue,  which  becomes  unusually  dense,  and  rich  in  nuclei.  The 
septa  are  swollen,  the  walls  of  the  vessels  thickened,  and  some  granule 
cells  are  observed.     The  consistence  of  the  cord  is  often  increased. 

§  483.  Diagnosis. — Typical  cases  of  acute  myelitis  are  easily 
recognised,  but  the  less  pronounced  cases  and  those  complicated 
by  the  presence  of  other  affections  are  difficult  to  unravel.     The 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  289 

characteristic  symptoms  are,  the  sudden  onset  of  the  affection, 
the  presence  of  more  or  less  marked  signs  of  sensory  and  motor 
irritation,  the  rapid  development  of  complete  paralysis  of  some 
of  the  limbs  and  of  the  bladder,  the  rapid  formation  of  bed- 
sores, and  the  presence  of  fever. 

Acute  myelitis  may  be  mistaken  for  the  following  diseases : — 

Acute  ascending  paralysis  resembles  diffuse  central  myelitis 
so  closely  that  it  is  scarcely  possible  to  distinguish  the  two 
affections.  Landry's  paralysis  is  characterised  by  the  absence 
of  convulsive  movements  at  the  onset  of  the  affection,  absence  of 
trophic  disturbances,  slight  degree  of  sensory  disturbances,  and 
the  preservation  of  the  faradic  contractility  of  the  paralysed 
muscles. 

Acute  meningitis  of  the  cord  is  characterised  by  high  fever, 
severe  pain,  dorsal  and  cervical  rigidity,  contractures,  slight 
symptoms  of  paralysis,  especially  of  the  sphincters,  absence  of 
severe  trophic  disturbances,  and  pronounced  hypersesthesia. 
The  two  diseases  are  often  combined,  and  then  the  difficulties 
of  diagnosis  become  greater. 

HcematoTnyelia  or  simple  haemorrhage  into  the  spinal  cord  is 
very  difficult  to  distinguish  from  central  myelitis,  especially 
from  the  hsemorrhagic  form  of  the  affection.  In  the  former  the 
paralysis  is  developed  suddenly  without  fever  or  prodromata, 
and  the  paralysis  is  stationary  instead  of  being  progressive  as 
in  the  latter. 

Hoematorrkachis  or  hasmorrhage  into  the  meninges  of  the 
cord  is  characterised  by  a  very  abrupt  development  without 
premonitory  symptoms  or  fever,  symptoms  of  severe  meningeal 
irritation,  violent  pains,  dorsal  rigidity,  a  comparatively  slight 
degree  of  paralysis,  and  particularly  by  the  slight  intensity  of 
the  anaesthesia. 

Hypercemia  of  the  cord  is  characterised  by  the  absence  of 
fever,  the  slight  intensity  of  the  sensory  and  motor  disturbances, 
the  frequent  and  rapid  variations  in  the  symptoms,  and  the 
absence  of  vesical  weakness  and  of  bed-sores. 

The  diagnosis  of  hysterical  paralysis  from  acute  myelitis  will 
hereafter  be  considered.      Several  poisons  produce  symptoms 
which  resemble  closely  those  of  acute  central  myelitis. 
T 


290  MIXED  DISEASES   OF  THE 

The  seat  of  the  disease  in  the  cord  and  its  extension  in  the 
transverse  and  vertical  directions  can  be  determined  from  the 
area  of  the  paralytic  phenomena,  the  state  of  the  reflex  irrita- 
bility, and  the  trophic  disorders. 

§  484.  Prognosis. — The  prognosis  is  generally  unfavourable, 
but  there  are  exceptions  to  this  rule.  Perfect  recovery  is  rare. 
In  many  cases  a  chronic  disease  is  induced ;  whilst  in  others 
there  is  arrest  of  the  disease,  but  incurable  defects  remain. 

The  prognosis  depends  on  the  locality  and  extent  of  the  in- 
flammatory process.  The  higher  up  the  disease  is  situated  in 
the  dorsal  and  cervical  regions,  the  greater  the  liability  of  the 
respiratory  tracts  to  become  affected  and  the  greater  is  the  danger 
to  life.  Dorsal  myelitis  is,  however,  other  things  being  equal, 
more  favourable  than  dorso-lumbar  myelitis,  because  the  genito- 
urinary automatic  centres  are  unaffected  in  the  former. 

The  prognosis  is  the  more  unfavourable  the  greater  the  extent 
of  the  transverse  section  of  the  cord  involved  in  the  process.  It 
is  rendered  very  unfavourable  when  the  central  and  posterior 
portions  of  the  grey  substance  are  involved,  owing  to  the  con- 
sequent cystitis  and  acute  bed-sores.  It  is  doubtful  how  far 
implication  of  the  white  columns  influences  the  prognosis. 

The  prognosis  also  becomes  worse  in  proportion  to  the 
longitudinal  extent  of  the  disease.  A  circumscribed  transverse 
myelitis  is  not  so  dangerous  as  the  same  affection  when  it 
extends  over  a  greater  length  of  the  cord.  The  progressive 
ascending  forms  of  the  disease,  and  particularly  of  central 
ascending  myelitis,  have  a  particularly  unfavourable  prognosis. 
A  longitudinal  extension  of  the  disease  in  the  white  columns  is 
not  so  dangerous. 

A  rapid  development  and  great  intensity  of  the  paralysis, 
complete  paralysis  of  the  sphincters,  early  formation  of  acute 
bed-sores,  progressive  advarice  of  the  disease  upwards,  high  fever, 
impairment  of  the  general  health,  dyspnoea,  cyanosis,  and  other 
disorders  of  respiration  influence  the  prognosis  unfavourably. 
A  moderate  degree  of  paralysis,  absence  of  trophic  and  sensory 
disturbances,  implication  of  the  bladder  to  only  a  slight  extent, 
absence  of  fever  and  of  marked  impairment  of  the  general 
health,  and  commencing  improvement  of  some  of  the  nervous 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  291 

symptoms  are  all  favourable  signs.  The  nature  of  the  causes 
of  the  affection  and  the  possibility  of  their  removal,  the 
occurrence  of  relapses,  the  state  of  the  general  health,  and  the 
effects  produced  by  treatment  are  other  elements  which  should 
be  taken  into  account  in  forming  a  prognosis. 

§  485.  Treatment. — In  acute  diffused  myelitis  the  patient 
should  maintain  absolute  rest  in  bed,  and  lie  as  much  as  pos- 
sible on  his  side  or  abdomen,  while  Chapman's  ice-bag  is  applied 
to  the  spine.  It  is  also  desirable  to  place  the  patient  on  a  water 
bed,  and  the  parts  exposed  to  pressure  should  be  sponged  with 
brandy  or  whisky,  and  dusted  with  an  absorbent  powder,  in 
order  to  prevent,  if  possible,  the  formation  of  bed-sores. 

Internal  remedies  do  not  appear  to  be  of  much  use  in  the 
treatment  of  acute  myelitis ;  but  ergot  or  belladonna  is  supposed 
to  do  good  in  the  early  stage  of  the  disease,  and  iodide  of  potas- 
sium may  be  given  to  promote  absorption  when  the  fever  has 
subsided.  A  saline  mixture  may  be  given  in  order  to  maintain 
the  activity  of  the  skin  and  kidneys,  while  the  bowels  should  be 
gently  acted  on  by  mineral  waters  containing  sulphate  of  mag- 
nesia, or  by  senna,  rhubarb,  or  castor  oil.  When  myelitis 
becomes  developed  in  the  course  of  syphilis,  energetic  mer- 
curial treatment  in  combination  with  large  doses  of  iodide  of 
potassium  is  to  be  adopted. 

Counter  irritation  to  the  spine  should  be  used  in  great 
moderation,  for  fear  of  favouring  the  formation  of  bed-sores. 
In  cases  where  the  disease  is  situated  in  the  dorsal  and  upper 
cervical  regions  a  blister  may  be  applied,  or  a  hot  iron  may  be 
used;  but  counter  irritants  should  never  be  applied  in  cases 
where  the  skin  is  anaesthetic,  and  all  the  parts  exposed  to  con- 
tinuous pressure  should  be  avoided  in  their  application. 

The  galvanic  current  should  never  be  employed  in  the  acute 
stage  of  myelitis,  but  it  is  useful  in  the  treatment  of  the 
sequelae  of  the  affection,  and  in  the  treatment  of  the  more  chronic 
forms.  The  diet  should  be  easily  digestible  and  nourishing, 
and  no  tea,  coffee,  or  alcohol  should  be  allowed. 

Great  care  should  be  used  in  introducing  the  catheter  for 
fear  of  setting  up  or  aggravating  the  cystitis.  The  catheter 
should  always  be  washed  in  carbolic  acid  lotion,  and  lubricated 


292  MIXED   DISEASES   OF  THE 

with  carbolic  oil,  in  order  to  prevent  the  introduction  of  bacteria 
into  the  bladder.  When  the  disease  has  become  subacute  or 
chronic,  the  treatment  must  be  modified  accordingly. 

(III.)    CHRONIC   DIFFUSED    MYELITIS. 

Chronic  Inflammation  of  the  Spinal  Cord. 

§  486.  Definition. — Chronic  diffused  myelitis  comprises  all 
those  slowly-developing  and  diffused  processes  in  the  spinal 
cord  which  run  a  lingering  course  "v^^ithout  fever,  and  which  are 
at  present  ascribed  to  chronic  inflammation. 

§  487.  Etiology. — It  is  very  probable  that  individuals  in- 
heriting a  neuropathic  constitution  are  predisposed  to  myelitis, 
but  no  statistical  proof  has  as  yet  been  forthcoming.  The  other 
predisposing  causes  of  the  disease  are  mental  and  bodily  over- 
exertion, dissipation,  sexual  excesses,  syphilis,  emotional  excite- 
ment, especially  the  depressing  emotions.  The  disease  is  most 
common  during  youth  and  middle  age,  and  in  the  male  sex. 

Chronic  myelitis  can  develop  from  the  acute  form,  although 
the  former  can  be  produced  primarily  from  the  same  causes  as 
the  acute. 

The  following  are  the  usual  exciting  causes  of  the  affection  : — 
Exposure  to  cold,  long  sojourn  in  damp  and  cold  localities, 
sleeping  on  damp  earth,  bodily  over-exertion,  especially  when 
combined  with  exposure  to  cold,  as  occurs  during  campaigns. 
Simple  concussion  of  the  cord,  without  direct  injury,  and  gradual 
compression,  may  also  give  rise  to  chronic  myelitis,  and  sexual 
excess  may  act  both  as  a  predisposing  and  exciting  cause. 

Syphilis  is  a  fruitful  source  of  chronic  myelitis.  Syphilitic 
neoplasms  are  not  here  in  question,  but  cases  of  chronic  myelitis 
which  arise  in  the  course  of  secondary  syphilis,  or  in  persons 
who  had  previously  suffered  from  the  disease,  and  where  no 
specific  lesion  can  be  discovered  to  account  for  the  affection. 
It  is  probable,  therefore,  that  we  have  here  to  do  with  simple 
myelitis  in  persons  predisposed  by  syphilis  to  chronic  in- 
flammations. 

Chronic  myelitis  is  occasionally  developed  as  a  sequel  of 
various   acute   and   chronic    diseases,    such   as   lepra,   chronic 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  293 

alcoholism,  and  chronic  lead  poisoning.  It  may  also  he  developed 
from  irritation  and  diseases  of  peripheral  organs,  and  most  of 
the  cases  called  reflex  paralysis  belong  to  the  category  of  sub- 
acute and  chronic  myelitis. 

§  488.  Symptoms. — All  the  diseases  comprised  under  the 
term  chronic  myelitis  cannot  be  included  in  one  general  descrip- 
tion. The  following  description  applies  more  particularly  to 
transverse  myelitis,  where  one  large  focus  of  disease  exists  at 
any  height  in  the  cord,  or  where  there  are  several  foci,  one  of 
which,  however,  determines  the  chief  clinical  features  of  the 
affection.  In  the  majority  of  the  cases  belonging  to  this  class 
the  symptoms  develop  slowly  and  gradually.  Sensory  disturb- 
ances are  first  complained  of,  consisting  of  abnormal  sensations 
and  anaesthesia  in  the  lower,  more  rarely  in  the  upper  extremi- 
ties, and  these  may  entirely  disappear  for  a  time.  They  are 
frequently  accompanied  by  a  girdle  sensation  in  the  trunk,  or 
perhaps  also  in  the  extremities.  Painful  sensations,  severe 
pains,  and  hypersesthesia  are  rarely  complained  of  The  symp- 
toms are  variable  and  inconstant,  and  only  attain  a  high  degree 
of  intensity  very  slowly  and  gradually. 

Of  the  motor  disturbances  which  occur  in  the  early  stage  of 
the  affection  those  of  motor  irritation  are  of  subordinate  im- 
portance. These  usually  consist  of  slight  twitching  movements 
of  the  legs,  or  the  patient  may  experience  slight  muscular 
contractions  and  trembling  of  the  legs  after  prolonged  exertion. 
The  paralytic  symptoms  are  usually  more  prominent  and  im- 
portant. The  first  motor  symptoms  to  attract  the  patient's 
attention  are  a  feeling  "of  weakness  and  heaviness  of  the  limbs 
and  an  undue  sense  of  fatigue  on  slight  exertion.  These 
symptoms  may  at  first  be  relieved  by  walking,  patients  often 
feeling  stiffer  and  more  fatigued  at  starting  than  after  they 
have  walked  for  some  time.  The  affection  occasionally  begins 
by  vesical  weakness  manifested  by  slight  incontinence  or  reten- 
tion, while  on  rare  occasions  the  onset  may  be  marked  by 
pronounced  paralysis  of  the  bladder. 

As  the  disease  advances  the  symptoms  become  slowly  and 
progressively  aggravated,  or  become  suddenly  worse  under  the 
influence  of  one  of  the  exciting  causes  of  the  affection. 


294  MIXED  DISEASES   OF  THE 

The  stiffness  and  weakness  of  the  lower  extremities  now 
become  more  marked,  the  legs  feel  as  if  they  were  made  of  lead, 
and  the  feet  are  slowly  dragged  along  the  ground,  the  toes 
catching  readily  in  every  inequality.  The  movements  of  the 
toes,  and  of  the  fingers  if  the  upper  extremities  be  implicated 
in  the  paralysis,  are  slowly  performed,  each  of  them  being 
accompanied  by  a  large  number  of  associated  movements.  The 
paralysis  generally  assumes  the  typical  form  of  spinal  paraplegia, 
although  occasionally  it  appears  as  spinal  hemiplegia,  and  still 
more  rarely  the  arms  may  be  paralysed,  while  the  legs  remain 
very  little  or  not  affected. 

Ancestkesia  of  varying  forms  and  degrees  of  intensity,  usually 
involving  the  lower  extremities  and  the  trunk  up  to  a  variable 
height,  is  rarely  wanting.  Retardation  of  sensory  conduction 
and  various  parsesthesise  are  often  observed,  and  the  patients 
occasionally  complain  of  dyssesthesise. 

The  reflex  activity  is  increased  in  the  majority  of  cases,  and 
a  variety  of  reflex  movements  may  be  produced  by  irritation  of 
different  sensitive  surfaces.  Tickling  the  soles  of  the  feet  causes 
active  jerking  and  kicking  movements  in  the  paralysed  legs ; 
while  the  introduction  of  a  catheter,  or  the  act  of  dressing  a 
bed-sore,  may  also  excite  movements  in  them.  Evacuation  of 
urine  may  be  produced  by  irritating  the  skin  of  the  feet  or  by 
introducing  the  finger  into  the  rectum,  erections  may  be  pro- 
duced by  rubbing  the  inside  of  the  thighs,  and  a  discharge  of 
foeces  often  occurs  during  the  dressing  of  a  bed-sore. 

The  tendon  reflexes  are  as  a  rule  abnormally  active,  the 
reactions  obtained  being  similar  to  those  described  under 
spastic  spinal  paralysis.  In  some  cases  the  various  reflexes  are 
diminished  or  even  entirely  abolished.  In  these  cases  the  grey 
substance  is  extensively  involved,  or  the  conducting  fibres  of 
the  various  reflex  arcs  are  destroyed  as  they  pass  through  the 
nerve  roots. 

The  vaso-motor  disturbances  are  as  a  rule  not  very  prominent. 
The  patients  complain  of  coldness  of  the  feet,  and  the  limbs 
are  often  of  a  cyanotic  or  bluish-red  colour. 

The  electric  irritability  of  the  nerves  and  muscles  is  generally 
preserved,  both  quantitatively  and  qualitatively,  when  the  reflex 
actions  persist,  and  in  some  cases  both  faradic  and  galvanic 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  295 

irritability  may  be  increased.  When  the  reflexes,  however,  are 
abolished,  in  consequence  of  extensive  destruction  of  the  grey 
matter,  the  muscles  undergo  atrophy  accompanied  by  loss  of 
their  faradic  excitability  and  the  reaction  of  degeneration.  The 
distribution  of  the  atrophy  is  very  variable.  At  times  the  upper 
extremities  are  alone  or  chiefly  affected  by  the  atrophy,  the 
lower  limbs  presenting  simple  paralysis  without  atrophy. 

In  transverse  myelitis  bed-sores  are  sooner  or  later  developed 
in  the  usual  places.  The  bed-sores  usually  assume  the  chronic 
form,  altliough  they  may  occasionally  pursue  an  acute  course. 
In  some  rare  cases  large  sloughs  may  become  permanently  cica- 
trised, even  though  there  be  no  noticeable  improvement  in  the 
other  symptoms  of  the  disease. 

The  sphincters  are  almost  always  involved  to  a  more  or  less 
extent,  and  the  vesical  functions  are  particularly  liable  to  be  im- 
paired at  an  early  period,  but  there  are  some  exceptional  cases 
in  which  the  bladder  remains  unaffected  thoughout  the  entire 
course  of  the  disease. 

Sexual  power  is  usually  impaired  at  an  early  period.  It 
diminishes  with  more  or  less  rapidity,  and  finally  disappears 
entirely.  In  cases  of  incomplete  paraplegia  sexual  power  may 
be  preserved  for  a  long  time. 

The  general  health  may  remain  perfect  for  a  long  time  ;  but 
in  all  the  more  severe  cases  a  constantly  increasing  dis- 
turbance of  general  nutrition  is  observed,  which  becomes  more 
marked  as  soon  as  cystitis  and  bed-sores  are  developed.  Loss 
of  appetite,  fever,  progressive  emaciation,  and  exhaustion  con- 
stitute the  final  symptoms,  provided  life  be  not  terminated 
sooner  by  some  acute  intercurrent  disease. 

The  cerebral  nerves  are,  as  a  rule,  not  implicated  in  cases  of 
chronic  transverse  myelitis,  except  towards  the  termination  of 
the  disease.  In  some  cases  the  morbid  process  ascends  until  it 
at  last  reaches  the  medulla  oblongata,  giving  rise  to  disorders 
of  deglutition,  speech,  circulation  and  respiration,  and  ulti- 
mately causing  death  by  asphyxia. 

§  489.  Course,  Dwration,  and  Terminations. — When  the 
chronic  is  preceded  by  the  acute  form,  the  onset  of  the  disease 
is  of  course  sudden.    In  most  cases,  however,  the  disease  super- 


296  MIXED  DISEASES   OF  THE 

venes  slowly  and  gradually,  so  that  the  first  symptoms  attract 
little  or  no  attention.  The  development,  instead  of  being 
continuous,  is  sometimes  marked  by  intervals  of  more  or  less 
improvement,  which  alternate  with  exacerbations  and  slight 
relapses. 

The  disease  on  attaining  a  certain  height  may  remain  sta- 
tionary for  many  months  or  even  years,  or  it  may  slowly  progress 
and  terminate  in  different  ways.  The  duration  of  the  affection 
generally  extends  over  many  years,  and  in  some  cases  it  may 
last  a  lifetime  without  producing  dangerous  symptoms. 

Complete  recovery  is  rare,  and  even  in  those  rare  cases 
relapses  are  liable  to  occur.  Various  symptoms,  such  as  para- 
lysis, atrophies,  partial  ansesthesise,  deformities,  vesical  dis- 
orders, and  other  affections,  often  remain  behind  permanently. 
The  usual  course  of  the  disease  is  a  slowly  progressive  one, 
leading  gradually  and  in  different  ways  to  a  fatal  termination. 
The  process  may  slowly  creep  upwards  until  disturbances  of 
deglutition  and  respiration  occur,  and  death  results  from 
asphyxia.  At  other  times  the  secondary  affections  caused  by 
the  myelitis,  such  as  bed-sores,  cystitis,  pyaemia,  and  septicaBmia, 
destroy  the  vital  powers  of  the  patient  and  lead  to  death  by 
exhaustion  and  marasmus.  In  a  large  number  of  cases  death  is 
caused  by  an  intercurrent  affection,  such  as  pneumonia. 

§  490.  Morbid  Anatomy. — The  morbid  appearances  pre- 
sented by  the  spinal  cord  are  often  so  slight  that  they  cannot 
be  detected  by  the  naked  eye.  In  many  cases,  however,  changes 
occur  in  the  consistence,  colour,  and  form  of  the  cord,  which  can 
be  readily  detected. 

It  is  unnecessary  to  repeat  here  what  has  already  been  said 
with  regard  to  sclerosis  or  grey  degeneration  (§  387).  It  will 
suffice  to  remind  the  reader  that  in  subacute  cases,  or  in  the 
earlier  stages  of  a  chronic  myelitis  which  has  developed  from 
the  acute  form,  the  tissue,  instead  of  being  found  in  a  state  of 
sclerosis  or  grey  degeneration,  may  have  undergone  softening, 
or  the  morbid  process  may  have  led  to  the  formation  of  cavities. 
It  must  also  be  remembered  that  a  chronic  myelitis  often  ter- 
minates by  an  acute  attack,  and  that  softening  may  be  found 
associated  with  sclerosis. 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  297 

In  chronic  myelitis  the  cord  undergoes  various  changes  of 
form,  according  to  the  extent  and  localisation  of  the  lesion. 
An  increase  of  volume  of  the  whole  or  circumscribed  parts  of 
the  cord  is  rare,  but  a  diminution  of  volume  or  atrophy  is 
common.  The  atrophy  may  be  general  and  affecting  the  trans- 
verse area  of  the  cord  equally  in  all  directions,  or  it  may  take 
place  in  particular  directions.  The  cord  may  be  flattened  in 
the  antero-posterior  direction,  so  that  it  presents  the  appearance 
of  a  band,  or  the  surface  may  be  depressed  the  entire  length 
of  certain  columns,  as  the  posterior  columns  in  locomotor  ataxy, 
or  the  surface  may  be  depressed  in  isolated  and  circumscribed 
spots. 

Microscopic  Examination. — Changes  have  been  observed  in 
the  (1)  connective  tissue,  (2)  the  nervous  tissues,  and  (3)  in  the 
blood-vessels. 

(1)  Connective  Tissue  or  the  Neuroglia. — The  connective 
tissue  septa  become  thickened,  the  neuroglia  cells  enlarge  and 
their  nuclei  undergo  proliferation,  while  Deiter's  cells  become 
greatly  increased  in  size  and  number.  After  a  time  the  normal 
neuroglia  becomes  converted  into  a  dense,  fibrillated  connective 
tissue  in  which  a  large  number  of  nuclei  may  be  observed. 

(2)  Nervous  Tissues. — The  nerve  fibres  undergo  changes 
which  correspond  to  some  extent  with  the  secondary  degeneration 
of  the  fibres  of  peripheral  nerves.  The  medullary  sheath  becomes 
irregularly  thickened,  then  undergoes  granular  and  fatty  degene- 
ration, and  is  finally  absorbed.  The  axis  cylinders  become  at 
first  much  swollen,  so  that  they  may  attain  two  or  three  times 
their  normal  dimensions,  but  when  they  are  viewed  longitudi- 
nally they  are  seen  to  present  spindle-shaped  enlargements. 
After  the  disappearance  of  the  medullary  sheath  the  naked 
axis  cylinders  may  often  be  observed  for  a  considerable  time 
longer,  but  after  a  time  they  also  undergo  atrophy  and  dis- 
appear, so  that  nothing  remains  but  a  dense  fibrillated  connec- 
tive tissue.  The  ganglion  cells  are  cloudy  and  swollen  at  first, 
but  after  a  time  they  undergo  various  forms  of  atrophy  and 
vacuolation. 

(8)  Changes  in  the  Vessels. — The  walls  of  the  small  arteries 
and  veins,  and  probably  of  the  capillaries  also,  become  thickened, 
while  their  calibre  is  lessened.     The  walls  of  the  vessels  are 


298  MIXED   DISEASES  OF   THE 

often  adherent  to  the  indurated  connective  tissue,  so  that  the 
lymph  spaces  are  destroyed.  In  other  cases  the  perivascular 
spaces  contain  collections  of  fat  and  pigment  granules,  and 
occasionally  granule  cells  also.  Granule  cells  and  corpora 
amylacea  are  observed  scattered  through  the  diseased  tissue, 

§  491.  Morbid  Physiology. — The  connection  between  the 
morbid  lesions  and  the  symptoms  is  the  same  in  the  chronic  as 
in  the  acute  varieties  of  myelitis,  so  that  it  is  unnecessary  to 
repeat  what  has  already  been  said  with  regard  to  the  morbid 
physiology  of  the  disease. 

§  492.   Varieties  of  Chronic  Diffused  Myelitis. 

The  following  varieties  of  chronic  diffused  myelitis  may  be 
distinguished  : — 1,  Chronic  central  myelitis  ;  2,  Chronic  trans- 
verse myelitis ;  3,  Universal  progressive  myelitis ;  4,  Chronic 
bulbar  myelitis ;  5,  Chronic  myelo-meningitis  ;  and  6,  Chronic 
disseminated  myelitis  or  multiple  sclerosis. 

1.  Chronic  Central  Myelitis. — (a)  The  subacute  genei'al  spinal  para- 
lysis of  Duchenne  is  probably  a  typical  example  of  inflammation  of  the 
central  grey  column,  with  extensions  of  the  process  into  the  anterior  horns, 
and  pursuing  a  gradually  ascending  course.  Chronic  atrophic  paralysis  is, 
indeed,  closely  similar  in  its  symptoms  to  Landry's  paralysis,  of  which  it 
may  be  regarded  as  the  chronic  form.  Hallopeau  has  shown  that  this 
form  of  paralysis  sometimes  pursues  a  descending  course.  In  these  cases 
the  upper  extremities,  especially  the  muscles  of  the  forearm,  become  first 
paralysed ;  they  undergo  atrophy  soon  afterwards,  and  the  hands  assume 
deformed  postures.  It  is  often  seven  or  eight  months  or  longer  before 
either  of  the  lower  extremities  are  affected,  and  it  may  be  several  months 
longer  before  both  of  them  are  implicated  in  the  paralysis.  But  even  in 
these  cases  the  disease  pursues  an  ascending  course  as  well,  bulbar 
symptoms  supervene  after  a  time,  and  death  results  from  paralysis  of  the 
respiratory  centres. 

(b)  Peri-ependymal  Myelitis — the  "  myellite  peri-ependymaire  "  of  Hal- 
lopeau— is  another  variety  of  chronic  central  myelitis.  The  symptoms 
are  characterised  by  paralysis  followed  by  diminution  of  the  faradic  con- 
tractility, and  atrophy  of  the  affected  muscles. 

The  paralysis  comes  on  somewhat  suddenly  ;  the  patient  finds  that  he 
is  not  able  to  move  the  fingers,  hands,  or  more  rarely  the  entire  limb. 
After  a  time  the  muscles  lose  their  faradic  contractility  and  become 
atrophied,  so  that  the  affected  extremities  assume  deformed  positions. 
Fibrillary  contractions  are  either  absent  or  only  present  in  a  slight 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  299 

degree.  The  patient  may  complain  of  vague  pains  along  the  vertebral 
column,  but  other  sensory  disturbances  are  usually  absent.  The 
sphincters  also  remain  unaffected.  The  course  of  the  affection  is  slow,  and 
it  may  be  temporarily  arrested  for  a  long  time.  The  muscles  most 
frequently  affected  are  the  flexors  of  the  foot  on  the  leg,  and  of  the  thigh 
on  the  pelvis  in  the  lower  extremities  ;  and  the  extensors  of  the  fingers 
and  of  the  hand,  then  the  muscles  of  the  hand,  and  lastly  the  flexors  and 
other  muscles  of  the  arm  and  shoulders.  This  affection  may  pursue  a 
descending  or  an  ascending  course,  and  in  the  latter  cases  bulbar  paralysis 
supervenes  and  death  is  caused  by  respiratory  paralysis.  Many  cases  of 
syringomyelia  and  hydromyelia  are  only  forms  of  chronic  central  myelitis. 
Peri-ependymal  myelitis  is  closely  allied,  on  the  one  hand,  with  the  sub- 
acute general  spinal  paralysis  of  Duchenne,  and  with  progressive  muscular 
atrophy  on  the  other.  And  if  we  compare  the  symptoms  of  Landry's 
paralysis,  subacute  general  spinal  paralysis,  peri-ependymal  myelitis,  and 
progressive  muscular  atrophy,  it  is  impossible  not  to  be  struck  with  the 
essential  unity  which  underlies  them,  while  their  differences  are  no  less 
instructive. 

All  these  diseases  are  characterised  by  a  progressively-invading  para- 
lysis, which  may  pursue  an  ascending  or  a  descending  course,  and  by 
almost  entire  absence  of  sensory  disturbances,  bed-sores,  and  paralysis  of 
the  sphincters.  The  most  striking  differences  between  them  are  found  in 
the  time  occupied  in  development  of  the  symptoms,  and  in  the  course  of 
the  disease.  Landry's  paralysis  is  sudden  in  its  onset  and  rapid  in  its 
progress ;  while,  on  the  contrary,  progressive  muscular  is  gradual  in  its 
onset  and  slow  in  its  progress,  and  the  other  two  diseases  occupy  inter- 
mediate positions  between  these  with  respect  to  their  development  in 
time.  In  Landry's  paralysis  there  is  no  decided  muscular  atrophy,  and  the 
faradic  contractility  is  nearly  normal ;  in  subacute  general  spinal  paralysis 
there  is  decided  muscular  atrophy,  rapid  loss  of  faradic  contractility,  and 
the  reaction  of  degeneration ;  in  peri-ependymal  myelitis  there  is  also  pro- 
nounced atrophy,  and  the  faradic  contractility  becomes  slowly  and  gradually 
diminished,  while  in  progressive  muscular  atrophy  the  atrophy  and  para- 
lysis proceed  usually  side  by  side,  and  the  faradic  contractility  is  generally 
normal  so  long  as  any  muscle  remains. 

We  shall  hereafter  show  that  the  morbid  anatomy  of  these  diseases 
tends  to  explain  the  differences  just  described,  on  the  supposition  that  all 
are  only  different  kinds  of  inflammation  of  the  central  grey  columns 
of  the  cord,  with  anterior  and  lateral  extensions  of  the  disease  into  the 
anterior  grey  horns. 

(c)  Chronic  Central  Borso- Lumbar  Myelitis.— In  this  variety  of  the 
disease  tlie  symptoms  correspond  to  the  affection  already  described  as  acute 
central  myelitis.  The  lower  extremities  are  paralysed,  the  limbs  are 
flaccid,  the  muscles  undergo  atrophy,  and  the  faradic  contractility  of 
the  paralysed  muscles  is  soon  lost ;  the  reaction  of  degeneration  is  present, 
and  the  paralysis  may  gradually  ascend  to  the  muscles  of  the  trunk  and 


300  MIXED  DISEASES   OF  THE 

those  of  the  upper  extremities.  So  far  then  the  symptoms  of  this  affection 
correspond  to  those  of  subacute  general  spinal  paralysis  of  Duchenne,  but 
other  symptoms  are  observed  in  the  former  which  do  not  occur  in  the 
latter.  These  symptoms  are  oedema  of  the  lower  extremities,  paralysis  of 
the  sphincters,  bed-sores,  and  arthropathies.  Sensory  disturbances  also 
exist,  consisting  of  various  paraesthesiee  and  hyperalgesia,  followed  by 
varying  degrees  of  analgesia.  If  the  myelitis  be  limited  to  the  grey  sub- 
stance, tactile  sensibility  and  the  sense  of  locality  and  of  temperature 
remain  unaffected.  If  the  lower  portion  of  the  cord  be  not  implicated  in 
the  disease,  the  reflex  of  the  sole  may  be  exaggerated  in  the  early  stage  of 
the  disease.  This  form  of  myelitis  is  seldom  if  ever  chronic  from  the 
commencement,  and  results  usually  as  the  sequel  of  an  acute  attack. 

Morbid  Anatomy. — It  is  unnecessary  to  say  much  at  present  with 
regard  to  the  morbid  anatomy  of  the  chronic  forms  of  central  myelitis. 
It  appears  to  me  that  Landry's  paralysis,  chronic  atrophic  spinal  paralysis, 
peri-ependymal  myelitis,  progressive  muscular  atrophy,  and  what  I  have 
termed  chronic  central  dorso-lumbar  myelitis  are  only  different  forms  of 
inflammation  of  the  central  grey  column  of  the  cord.  In  Landry's 
paralysis  the  inflammatory  process  is  very  acute,  and  keeps  limited  to  the 
central  column  and  the  embryonic  areas  (the  medio-lateral  area  in  the 
dorsal  and  upper  cervical  regions,  and  the  median  areas  and  margins  of 
the  groups  of  ganglion  cells  in  the  lumbar  and  cervical  enlargements) 
of  the  anterior  grey  horns.  The  muscles  thus  still  maintain  their 
connection  with  the  fundamental  cells,  and  their  faradic  contractility 
and  nutrition  remain  comparatively  unaffected.  In  chronic  atrophic 
paralysis  the  morbid  process  pursues  the  same  ascending  or  descending 
course,  but  the  fundamental  ganglion  cells  are  invaded  and  destroyed, 
hence  muscular  atrophy  and  loss  of  faradic  contractility  result.  Peri- 
ependymal myelitis  pursues  a  somewhat  similar  course,  but  the  funda- 
mental cells  are  not  invaded  at  so  early  a  period  as  in  the  chronic 
atrophic  variety.  Progressive  muscular  atrophy  pursues  a  still  more 
chronic  course.  The  disease,  indeed,  appears  to  be  a  parenchymatous  one, 
and  to  spread  from  fibre  to  fibre  and  from  cell  to  cell.  It  appears  to  begin 
in  the  small  cells  and  fine  fibres  which  lie  near  the  central  artery,  and  to 
spread  gradually  upwards  and  downwards  and  laterally.  In  its  lateral 
extension  the  ganglion  cells  which  were  last  developed  become  first 
affected,  and  the  process  gradually  spreads  to  the  more  fundamental  cells. 
It  will  be  apparent  that  in  such  a  gradual  process  as  this  the  muscular 
paralysis  and  atrophy  will  pursue  a  parallel  course,  and  that  the  faradic 
contractility  will  be  maintained  so  long  as  the  fundamental  cells  are  able 
to  perform  their  functions  even  imperfectly,  and  long  after  they  have 
become  partially  diseased. 

In  the  form  of  the  disease  which  I  have  named  chronic  central 
dorso-lumbar  myelitis  the  affection  apparently  begins  as  an  acute 
central  myelitis,  and  then  assumes  a  chronic  form.  It  pursues  an 
ascending  course,  but  is  not  so  surely  invading  as  Landry's  paralysis  and 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  301 

chronic  atrophic  paralysis.  The  morbid  process,  on  the  other  hand, 
extends  backwards  to  the  posterior  grey  horns,  and  thus  gives  rise  to 
analgesia ;  but,  if  it  remain  limited  to  the  grey  matter,  the  tactile  sensi- 
bility is  comparatively  unaffected.  The  sphincters  also  become  para- 
lysed, and  bed-sores  appear  on  the  sacrum.  Recovery  may  take  place 
even  after  bed-sores  have  formed ;  but  if  the  affection  has  become  chronic, 
many  of  the  muscles  of  the  lower  extremities  remain  permanently  atro- 
phied. The  disease  may  extend  in  the  lumbar  region  into  the  white  sub- 
stance; and  if  death  supervenes,  a  transverse  myelitis,  with  ascending 
sclerosis  of  the  columns  of  GoU,  and  the  direct  cerebellar  tract  and 
descending  sclerosis  of  the  pyramidal  tracts,  will  be  found  associated  with 
the  morbid  appearances  usually  observed  in  central  myelitis.  Such  were 
the  conditions  observed  in  a  case  under  the  care  of  Dr.  Simpson,  in  which 
I  conducted  the  post-mortem  examination.  The  prominent  symptoms 
during  life  were  paralysis  with  flaccidity  of  limbs,  muscular  atrophy,  and 
loss  of  the  faradic  and  reflex  excitability,  ultimately  associated  with 
anaesthesia  and  paralysis  of  the  sphincters.  At  no  time  did  the  symptoms 
indicate  a  spastic  condition  of  the  muscles.  On  microscopic  examination 
the  lower  dorsal  region  of  the  cord  was  disorganised  in  the  whole  of  its 
transverse  diameter,  there  was  ascending  sclerosis  of  the  columns  of  Goll, 
and  of  the  direct  cerebellar  tracts,  while  the  pyramidal  tracts  were 
sclerosed  in  the  lumbar  region.  The  central  grey  column  was  diseased 
from  the  conus  meduUaris  up  to  the  lower  end  of  the  medulla.  In  the 
upper  dorsal  and  cervical  regions,  however,  the  fundamental  cells  appeared 
quite  healthy,  while  the  accessory  cells  had  disappeared.  The  condition 
of  the  grey  substance  in  this  cord  in  the  cervical  region  is,  indeed,  repre- 
sented in  Fig.  146. 

In  a  case  of  what  I  must  regard  as  in  the  main  a  central  myelitis,  under 
the  care  of  Dr.  Morgan,  the  morbid  appearances  discovered  differed  from 
those  observed  in  Dr.  Simpson's  case.  The  patient  under  Dr.  Morgan 
was  run  over  and  had  his  sciatic  nerve  injured.  This  was  followed  by 
paraplegia,  characterised  by  flaccidity  of  limbs,  and  muscular  atrophy.  A 
few  weeks  after  the  accident  spontaneous  fracture  of  the  neck  of  the  right 
femur  occurred.  After  a  time  there  was  ansesthesia  of  the  lower  extre- 
mities, paralysis  of  the  sphincters,  bed-sores,  and  death  from  pysemia  and 
peritonitis.  The  posterior  columns  of  the  cord  could  be  seen  with  the 
naked  eye  to  be  gelatinous  in  appearance.  On  microscopic  examination 
the  presence  of  sclerosis  of  the  posterior  columns  of  the  cord  was  con- 
firmed. The  portion  of  the  posterior  columns  which  adjoins  the  posterior 
commissure  was  healthy  in  the  lumbar  region,  the  whole  of  the  columns 
were  diseased  in  the  dorsal  region,  but  in  the  lower  cervical  region  the 
portions  which  adjoin  the  posterior  grey  horns  were  healthy,  and  the 
healthy  areas  gradually  increased  in  size  until  in  the  upper  cervical  region 
the  sclerosis  was  limited  to  the  columns  of  Goll.  In  addition  to  the 
sclerosis  of  the  posterior  columns,  the  central  grey  columns  were  found 
diseased  throughout  the  entire  length  of  the  cord,  accompanied  with  the 


302  MIXED   DISEASES   OF   THE 

usual  lateral  extensions  into  the  embryonic  areas  of  the  anterior  grey 
horns.  I  have  observed  similar  morbid  appearances — posterior  sclerosis 
and  central  myelitis — in  a  case  of  tumour  pressing  upon  the  cauda  equina. 

2.  Chronic  Transverse  Myelitis— The  symptoms  vary  according  to 
the  level  at  which  the  cord  is  diseased.  This  affection  may  be  subdivided 
into  (a)  chronic  dorso-lumbar,  (6)  chronic  dorsal,  (c)  chronic  cervical 
transverse  myelitis,  and  {d)  compression  myelitis. 

(a)  Chronic  Dorso-Lumbar  Transverse  Myelitis. — The  paralytic  symp- 
toms are  often  preceded  by  girdle  pains,  formication,  numbness,  and 
various  other  paraesthesise,  and  by  lancinating  pains  in  the  lower  extre- 
mities. The  patient  often  complains  of  muscular  cramps,  especially  in 
the  calves  of  the  legs  ;  he  is  soon  fatigued,  and  the  movements  are  stiff 
and  constrained.  After  a  time  the  lower  extremities  become  rigid  by  con- 
tractures, the  gait  assumes  the  spastic  form,  and  both  the  superficial  and 
deep  reflexes  are  exaggerated.  If  the  lesion  be  situated  below  the  origin  of 
the  sixth  lumbar  nerves  the  patellar-tendon  reflex  is  abolished.  The 
sensory  disturbances  also  increase,  the  patient  cannot  feel  the  floor,  and 
he  finds  it  necessary  to  direct  his  eyes  to  the  ground  ;  tactile  sensibility 
and  the  sense  of  locality  and  temperature  are  generally  impaired,  while 
in  advanced  cases  there  may  be  retardation  of  sensory  conduction  and 
analgesia.  The  general  health  may  be  unaffected  for  a  long  time,  but  by- 
and-by  the  paraplegia  becomes  complete,  and  the  various iforms  of  sensi- 
bility become  more  profoundly  affected,  so  that  at  last  there  may  be 
complete  anaesthesia  of  all  forms  of  sensibility.  Muscular  atrophy, 
accompanied  by  loss  of  the  reflex  and  faradic  contractility,  may  now 
supervene,  the  sphincters  are  paralysed,  bed-sores  form  over  the  parts 
exposed  to  mechanical  pressure,  and  the  patient  dies  from  pyaemia  and 
marasmus. 

(6)  Chronic  Dorsal  Transverse  Myelitis. — In  this  form  both  the  sensory 
and  motor  paralysis  extends  higher  than  in  the  dorso-lumbar  variety.  The 
condition  of  the  lower  extremities  with  regard  to  paralysis,  contractures, 
spastic  walk,  and  exaggerated  reflexes  is  the  same  as  in  the  dorso- 
lumbar  form  of  the  disease.  When  the  lesion  is  situated  in  the  upper 
portion  of  the  dorsal  region,  the  muscles  of  the  back  and  abdomen  are 
involved  in  the  disease.  The  paralysis  of  the  abdominal  muscles  renders 
urination,  defecation,  and  forcible  expiratory  acts  difficult,  so  that  the 
patient  is  much  troubled  by  constipation,  and  he  cannot  clear  the  bron- 
chial tubes  thoroughly  from  mucus.  Death  is  therefore  liable  to  be  caused 
by  slight  bronchial  catarrh.  Valuable  information  may  be  obtained  with 
regard  to  the  level  at  which  the  cord  is  diseased  by  an  examination  of  the 
cremasteric,  gluteal,  abdominal,  epigastric,  dorsal,  and  scapular  reflexes. 
Erb  has  recently  described  a  case  in  which  a  spontaneous  subacute  dorsal 
transverse  myelitis  was  preceded  by  double  optic  neuritis. 

(c)  Chronic  Cervical  Tra^isverse  Myelitis. —The  initial  symptoms  now 
generally  begin  in  the  upper  extremities  which  become  paralysed  some 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  303 

time  before  the  lower  extremities.  As  the  disease  increases  all  the  four 
extremities  become  paralysed.  The  muscles  of  the  upper  extremities  after 
a  time  become  atrophied  and  lose  their  reflex  and  faradic  contractility, 
while  those  of  the  lower  extremities  are  in  a  state  of  contracture,  their 
faradic  contractility  being  preserved  and  the  superficial  and  deep  reflexes 
increased.  Various  oculo-pupillary  symptoms  are  also  commonly  present. 
When  the  upper  cervical  region  of  the  cord  is  diseased,  all  four  extremities 
are  affected,  but  the  nutrition  of  the  muscles  of  the  upper  as  well  as  those 
of  the  lower  extremities  remains  unaffected,  and  their  reflex  activity  is 
increased.  The  diaphragm  becomes  paralysed,  and  the  patient  suffers 
from  dyspnoea,  impairment  of  speech,  vomiting,  and  hiccough. 

Morbid  Anatomy. — The  morbid  anatomy  of  chronic  transverse  myelitis 
varies  according  to  the  level  at  which  the  cord  is  affected.  At  the  level 
of  the  principal  focus  of  disease  both  the  grey  and  white  substances  are 
affected,  and  this  portion  of  the  cord  may  be  softened  instead  of  being  in  a 
state  of  sclerosis.  Above  the  level  of  the  main  lesion  the  columns  of  Goll 
and  the  direct  cerebellar  tracts  undergo  ascending  sclerosis  ;  while  the 
pyramidal  tracts  undergo  descending  sclerosis  below  the  level  of  the  lesion. 
If  the  lesion  is  situated  low  down,  the  ascending  sclerosis  may  be  limited  to 
the  columns  of  Goll  and  the  descending  to  the  pyramidal  tracts  of  the 
lateral  columns.  If,  on  the  other  hand,  the  lesion  be  situated  high  up  in 
the  cord,  both  the  columns  of  Goll  and  the  direct  cerebellar  tracts  are 
affected  with  ascending  sclerosis,  and  the  pyramidal  tracts  and  the  columns 
of  Titrck  with  descending  sclerosis.  In  addition  to  these  changes  trans- 
verse myelitis  is  frequently  accompanied  by  central  myelitis,  which  may 
extend  up  into  the  medulla  oblongata.  Near  the  main  lesion  the  central 
myelitis  may  extend  forwards  so  as  to  destroy  all  the  ganglion  cells  of  the 
auterior  horns,  but  in  the  upper  portion  of  the  cord  and  in  the  medulla 
oblongata  the  accessory  ganglion  cells  are  alone  destroyed,  while  the 
fundamental  cells  remain  more  or  less  healthy. 

{d)  Compression  Myelitis. — This  is  a  very  common  form  of  myelitis,  and 
may  occur  along  with  any  disease  of  the  vertebral  column  or  membranes 
which  causes  a  slow  compression  of  the  cord.  The  symptoms  of  this 
affection  correspond  in  the  main  with  those  of  spontaneous  transverse 
myelitis.  The  characteristic  feature  of  the  affection  is  the  existence  of 
symptoms  which  indicate  local  disease  of  the  cord  for  some  time  previous 
to  the  development  of  definite  paraplegia.  The  most  usual  of  these 
symptoms  are  severe  pains  along  the  course  of  nerves  which  issue  from 
a  particular  level  of  the  cord,  cramps  in  the  muscles  supplied  by  those 
nerves,  local  paralysis  and  muscular  atrophy,  local  hypersesthesia  or 
anaesthesia,  and  pain  and  stiffness  of  the  back. 

Morbid  Anatomy. — The  morbid  anatomy  of  compression  myelitis  is  the 
same  as  that  of  the  transverse  varieties.  The  structure  of  the  cord  is 
destroyed  at  the  level  where  the  compression  has  been  applied ;  while 
there  is  ascending  sclerosis  above  the  level  of  the  lesion,  and  descending 
sclerosis  below  it.     Central  myelitis  is  frequently  present  also . 


304  MIXED   DISEASES   OF   THE 

3.  Universal  Progressive  Myelitis. — In  this  form  of  the  disease  the 
myelitis  gradually  extends  until  it  involves  the  whole  breadth  of  the  cord. 
It  is  characterised  by  progressive  weakness  of  the  muscles  of  the  lower  ex- 
tremities followed  by  complete  paralysis.  The  disease  generally  begins  in 
the  lower  extremities,  and  pursues  an  ascending  course ;  but  occasionally 
it  begins  in  the  upper  extremities,  and  then  its  course  is  descending. 
There  may  at  first  be  contracture  of  the  muscles,  and  this  is  followed  by 
gradual  atrophy  as  the  grey  substance  becomes  involved.  The  reflexes 
and  the  faradic  contractility  also  gradually  diminish  and  ultimately  dis- 
appear. There  may  be  more  or  less  violent  pains  in  the  back,  trunk,  and 
extremities,  the  patient  complains  of  paraesthesise  and  dyssesthesiee,  and 
after  a  time  there  is  complete  anaesthesia,  paralysis  of  the  sphincters,  and 
bed-sores. 

Morbid  Anatomy. — In  the  lumbar  and  lower  dorsal  regions  the  entire 
transverse  area  of  the  cord  is  diseased,  but  in  the  upper  dorsal  and  cervical 
regions  the  sclerosis  may  be  limited  to  the  columns  of  GoU  and  the  direct 
cerebellar  tract,  associated  sometimes  with  more  or  less  of  chronic  central 
myelitis. 

4.  Chronic  Bulbar  Myelitis.  —  The  most  characteristic  form  of 
chronic  bulbar  myelitis  has  already  been  described  as  chronic  progressive 
bulbar  paralysis,  but  cases  of  bulbar  paralysis  are  occasionally  observed 
which  do  not  possess  a  distinctly  progressive  character.  When  the  latter 
class  of  cases  is  caused  by  a  bulbar  myelitis,  the  aflfection  is  probably  in 
all  cases  produced  by  the  extension  of  inflammation  from  morbid  changes 
taking  place  in  the  neighbourhood  of  the  grey  nuclei  of  the  medulla 
oblongata.  Inflammation  of  the  bulbar  nuclei  may  in  this  manner  be  set 
up  by  tumours  of  the  neighbouring  structures,  or  they  may  be  involved  in 
the  inflammatory  zone  which  frequently  surrounds  heemorrhagic  foci  and 
centres  of  necrotic  softening. 

5.  Chronic  Myelo-meningitis. — This  form  of  myelitis  has  been  termed 
peripheric  or  cortical  myelitis  by  Vulpian,  because  it  consists  of  a  chronic 
inflammation  of  the  cord  extending  inwards  from  the  pia  mater.  It  is 
not  easy  to  recognise  this  form  of  myelitis  during  life  ;  but  its  presence 
may  be  suspected  when  the  symptoms  of  chronic  meningitis  are  accom- 
panied by  an  unwonted  degree  of  both  sensory  and  motor  paralysis.  The 
paralysis  is  generally  of  the  spastic  variety  and  muscular  atrophy  does 
not  occur.  It  may,  however,  be  assumed  that,  should  the  anterior  roots 
become  involved  in  the  disease,  muscular  atrophy  will  inevitably  take 
place.  In  some  cases  the  posterior  columns  are  more  involved  than  the 
lateral  tracts,  and  then  ataxic  symptoms  predominate  over  those  of 
paralysis. 

Morbid  Anatomy  .—The  most  characteristic  feature  of  the  morbid  ana- 
tomy of  this  affection  is  that  the  afiected  portion  of  the  cord  is  surrounded 
more  or  less  completely  by  a  ring  of  sclerosis.  Sometimes,  however,  the 
sclerosis  appears  to  spread  inwards  in  the  posterior  columns  to  a  greater 


SPINAL  COED  AND  MEDULLA  OBLONGATA.  305 

extent  than  elsewhere,  while  at  other  times  the  anterior  are  affected  to  a 
greater  degree  than  the  posterior  or  lateral  columns. 

6.  Chronic  Disseminated  Myelitis. — As  this  disease  is  not  usually 
limited  to  the  spinal  cord,  but  extends  as  a  rule  to  the  cerebrum  and  cere- 
bellum, its  description  will  fall  more  naturally  with  the  encephalo-spinal 
than  the  spinal  diseases. 

§  493.  Diagnosis. — Simple  chronic  transverse  myelitis  is  cha- 
racterised by  slow  development  of  paraplegia  with  relatively 
slight  irritative  motor  symptoms,  and  by  the  presence  of  more 
or  less  marked  sensory  and  vesical  disturbances,  contractures, 
increased  reflexes,  and  bed-sores.  The  affection  is  but  slightly 
progressive  in  character,  and  runs  a  tedious  course.  Transverse 
myelitis  can  as  a  rule  be  readily  distinguished  from  the  syste- 
matic affections  of  the  cord.  In  some  cases  of  the  latter,  how- 
ever, the  lesion  of  one  of  the  functional  systems  of  the  cord 
extends  to  neighbouring  systems,  and  combinations  are  thus 
produced  which  are  sometimes  very  difficult  to  distinguish  from 
transverse  myelitis.  Numerous  combinations  of  the  system- 
diseases  are  possible,  and  every  case  of  the  kind  requires  sepa- 
rate study  and  a  special  diagnosis, 

§  494.  Prognosis. — The  prognosis  is  generally  unfavourable  in 
simple  transverse  myelitis.  The  affection  is  always  severe  and 
dangerous,  and  the  most  that  can  usually  be  hoped  for  is  arrest  of 
the  morbid  process  with  considerable  loss  of  power  in  the  lower 
extremities.     Complete  recovery  is  exceptional. 

A  slow  progressive  course  must  be  looked  for  in  the  majority 
of  cases,  and  the  disease  generally  terminates  in  death  in  a  few 
years.  The  prognosis  will  be  determined  by  the  ascending 
tendency  of  the  disease,  the  occurrence  of  relapses,  and  by  the 
presence  or  absence  of  cystitis  and  bed-sores. 

§  495.  Treatment. — The  treatment  of  the  early  stages  of 
chronic  myelitis  must  be  conducted  on  the  same  general  prin- 
ciples as  are  applicable  to  the  acute  varieties.  So  long  as  any 
active  symptoms  of  irritation  are  present,  the  patient  should 
maintain  the  recumbent  posture,  while  all  the  usual  precau- 
tions against  the  formation  of  bed-sores  and  cystitis  must  be 
u 


806  MIXED  DISEASES   OF   THE 

adopted.  Ergot,  belladonna,  and  the  iodide  of  potassium  are 
the  internal  remedies  which  have  been  found  of  most  use.  If 
syphilis  be  suspected,  active  antisyphilitic  treatment  must  be 
employed.  Nitrate  of  silver  was  first  recommended  by  Wun- 
derlich  in  the  treatment  of  chronic  myelitis,  but  it  is  probably 
of  more  use  in  locomotor  ataxia  than  in  any  other  variety  of 
the  disease.  It  should  not  be  administered  in  cases  associated 
with  spasmodic  rigidity  of  the  muscles.  Arsenic,  phosphorus, 
and  cod-liver  oil  may  sometimes  be  found  useful,  but  strychnine 
is  positively  injurious. 

Counter  irritation  was  at  one  time  used  too  indiscriminately, 
and  the  results  obtained  were  not  very  gratifying.  The  use  of 
the  milder  counter-irritants,  such  as  flying  blisters,  may  be 
employed  with  advantage.  Brown-S^quard  praises  highly  the 
application  of  a  hot  douche,  from  98°  to  104°  F.,  for  two  or 
three  minutes  at  a  time.  The  stream  should  be  nearly  an  inch 
in  diameter.  The  greatest  reliance  must  be  placed  on  baths, 
hydropathy,  and  galvanism. 

Baths. — Erb  strongly  recommends  the  thermal  brine  baths 
(Rehme,  Nanheim).  The  temperature  should  not  be  above 
86° — 78°  F.,  and  the  immersion  not  too  prolonged,  and  the 
water  should  not  contain  an  excessive  quantity  of  carbonic  acid. 
Ordinary  brine  baths,  chalybeate,  and  mud  baths  are  much 
extolled  by  many  authors. 

Cold-water  cure  is  very  useful.  All  severe  and  strongly- 
exciting  procedures,  such  as  the  use  of  water  at  a  very  low  tem- 
perature, cold  douches,  and  sharp  slappings,  should  be  avoided, 
and  even  wet  packs  of  the  entire  body  have  proved  injurious 
(Erb).  Simple  rubbing  with  wet-cloths,  foot-baths,  sponging  the 
back,  hip-baths,  and  local  compresses  to  the  back  left  on  till 
they  become  warm,  appear  to  be  the  most  useful  measures.  The 
treatment  should  begin  with  baths  of  moderate  temperatures 
(68°— 77°  F.,  never  below  60°— 53°  F.),  and  should  not  be  too 
prolonged.  When  an  insufficient  reaction  follows  a  bath,  and 
chilliness  and  discomfort  are  produced,  the  treatment  should  be 
discontinued. 

The  galvanic  current  is  one  of  the  most  important  therapeutic 
agents  for  the  treatment  of  chronic  myelitis.  The  electrodes 
must  be  applied  differently  according  to  the  differences  in  the 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  307 

position  and  extent  of  the  forms  of  disease.  It  is  best  to  let 
both  poles  act  successively,  either  with  a  stabile  or  with  a  slowly 
labile  current.  The  currents  used  should  not  be  very  strong, 
and  each  application  should  be  of  short  duration.  The  treat- 
ment should  be  continued  for  months,  being  occasionally  inter- 
rupted only  to  be  recommenced  after  a  brief  pause.  It  is 
expedient  to  alternate  or  combine  galvanisation  with  other 
methods  of  treatment.  Some  few  cases  do  not  bear  well  the 
application  of  galvanism,  and  with  these  the  use  of  it  must  be 
discontinued. 

The  general  management,  the  diet,  and  the  mode  of  life 
of  the  patient  are  of  the  utmost  consequence.  Rest  and 
a  regular  mode  of  life  are  essential.  Over-exertion  of  any 
kind,  mental  as  well  as  bodily,  must  be  avoided.  Sexual 
intercourse  should  be  confined  within  the  strictest  limits  or 
completely  stopped.  All  excitement  and  violent  emotions  must 
be  prevented  as  much  as  possible.  The  diet  must  be  simple, 
nutritious,  and  easy  of  digestion,  and  cod-liver  oil  is  often  bene- 
ficial. Alcoholic  beverages,  coffee,  tea,  and  tobacco  should  be 
used  with  great  moderation.  Residence  in  a  mountainous  region 
at  a  moderate  elevation,  or  at  the  sea-side,  will  be  useful;  and 
it  is  advisable  that  the  winters  should  be  passed  in  the  south. 

When  the  patient  is  completely  paraplegic,  a  wheeled  chair 
may  be  used  so  as  to  permit  the  enjoyment  of  fresh  air,  and  when 
patients  are  bedridden,  care  should  be  taken  that  the  recum- 
bent posture  is  not  always  maintained,  but  occasionally  replaced 
by  the  lateral  or  abdominal  position. 

Pain  must  also  be  relieved  by  various  means,  the  subcutaneous 
injection  of  morphia  being  the  readiest  and  most  effectual 
method.  Other  serviceable  drugs  are  bromide  of  potassium, 
quinine,  bromide  of  quinine,  zinc,  and  valerian.  Cutaneous 
irritation,  electricity  either  in  the  form  of  the  faradic  brush  or 
galvanic  current,  Preissnitz's  compresses,  applications  of  chloro- 
form, and  frictions  with  veratrine  ointment  and  similar  agents, 
often  do  good  service.  For  the  paralysis,  atrophies,  and  anaes- 
thesia, which  persist  after  the  disease  has  run  its  course, 
electricity  is  the  best  remedy. 


308  MIXED   DISEASES   OF  THE 

(IV.)   MYELOMALACIA. 

§  496.  Simple  Softening  of  the  Spinal  Cord. — Softening  of 
the  spinal  cord  may  result  from  non-inflammatory  processes. 

§  497.  Symptoms. — The  symptoms  of  simple  softening  are 
exceedingly  obscure.  The  patient  first  complains  of  feelings  of 
numbness  and  feebleness,  generally  of  the  lower  extremities, 
which  gradually  increase  in  severity,  until  ultimately  ansesthesia 
of  the  lower  extremities  and  paraplegia  are  fully  established ; 
the  reflex  excitability  is  also  gradually  diminished  and  ultimately 
abolished.  To  these  symptoms  are  added  progressive  paralysis 
of  the  sphincters  of  the  bladder  and  anus,  and  in  the  final  stage 
bed-sores,  marasmus,  and  pyaemia. 

Brown-Sdquard  and  Hammond  assert  that  at  no  time  in  the 
course  of  the  disease  are  there  any  pains,  hyper sesthesia,  spasms, 
or  increase  of  the  reflex  excitability. 

§  498.  Morbid  Anatomy. — The  post-mortem  appearances  of 
simple  softening  are  similar  to  those  of  white  softening  caused 
by  previous  inflammation.  When  fatty  degeneration  assumes 
special  prominence,  the  softened  spot  may  assume  a  yellowish 
colour,  and  present  the  appearances  of  yellow  softening.  The 
softened  spot  usually  merges  imperceptibly  into  the  normal 
tissue.  The  microscopical  characters  are  not  well  known  ;  but 
it  may  be  presumed  that  the  nuclei  of  the  neuroglia  do  not 
multiply  to  such  an  extent,  and  that  the  corpuscular  elements 
and  granule  cells  are  less  abundant  in  simple  than  inflammatory 
softening. 

§  499.  Morbid  Physiology. — The  symptoms  of  simple  soften- 
ing are  caused  by  the  gradual  destruction  of  the  nerve  elements 
without  previous  irritation.  Softening  is  probably  in  all  cases 
caused  by  disease  of  the  vessels,  thrombosis,  and  embolism. 

§  500.  The  diagnosis  must  rest  mainly  on  the  absence  of 
all  symptoms  of  sensory  and  motor  irritation  during  the  entire 
course  of  the  affection.  The  prognosis  of  the  affection  is  de- 
cidedly unfavourable  when  the  centres  of  softening  are  at  all 
extensive. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA,  309 

§  501,  The  treatment  must  be  carried  on  according  to  the 
rules  laid  down  for  the  chronic  forms  of  myelitis.  Brown- 
S^quard  recommends,  besides  iron  and  quinine,  iodide  of 
potassium  in  a  bitter  infusion,  and  strychnine  used  with  the 
greatest  caution,  while  he  avoids  ergot  and  belladonna.  He 
also  thinks  that  the  cold  douche  or  shower  bath  to  the  back 
is  indicated,  and  maintenance  of  the  dorsal  position.  The  food 
should  be  abundant  and  nourishing,  and  when  possible  moderate 
exercise  should  be  taken.  The  use  of  the  galvanic  current  will 
be  found  advantageous. 


310 


CHAPTEE  VI. 


III.— VASCULAR  DISEASES  OF  THE  SPINAL  CORD  AND 
MEDULLA  OBLONGATA. 

(I.)    ANEMIA,   THROMBOSIS,  AND  EMBOLISM   OF   THE   SPINAL 
CORD   AND   MEDULLA  OBLONGATA. 


1.  Ancemia  of  the  Cord. 

§  502.  Ansemia  of  the  spinal  cord  consists  of  a  diminution 
in  the  amount  of  blood  contained  in  it.  This  condition  may 
be  due  to  causes  special  to  the  cord  itself,  and  then  it  is 
called  spinal  ischcemia;  or  to  general  causes,  such  as  oligsemia 
and  hyrdsemia,  and  then  it  is  called  dyscrasic  spinal  ancemia 
(Jaccoud). 

§  503.  Etiology. — The  predisposing  causes  of  spinal  ansemia 
are  congenital  narrowness  of  the  calibre  of  the  vessels,  weakness 
of  the  heart,  and  undue  excitability  of  the  vaso-motor  nerves. 
The  female  sex  is  strongly  predisposed  to  spinal  ansemia. 
Diseases  of  the  vessels  of  the  cord,  such  as  atheroma  or  the 
fibrosis  which  accompanies  Bright's  disease,  also  produce  spinal 
ansemia.  The  exciting  causes  of  the  affection  are  arrested  or 
diminished  circulation,  as  may  be  produced  by  compression, 
thrombosis,  or  embolism  of  the  abdominal  aorta  above  the 
point  of  origin  of  the  lumbar  arteries. 

Owing  to  the  numerous  anastomoses  of  the  spinal  arteries, 
thrombosis  and  embolism  of  one  or  more  of  them  only  lead 
to  circumscribed  ischsemia.  It  is  probable  that  a  considerable 
number  of  the  so-called  reflex  paralyses  are  caused  by  a  reflex 
spasm  of  the  spinal  arteries,  and  direct  irritation  of  the  vaso- 
motor conducting  paths  in  the  cord  may  likewise  produce  spasm 
of  these  vessels. 


VASCULAR  DISEASES  OF   THE   SPINAL   CORD.  311 

The  cases  of  spinal  ansetnia  which  arise  from  general  causes 
have  been  described  by  Jaccoud  under  the  name  of  parapUgies 
dyscrasiques. 

Spinal  paralysis  occurs  only  rarely  in  dyscrasic  ansemia  of 
the  cord,  but  paraplegia  has  been  known  to  follow  great  losses 
of  blood,  as  in  parturition,  monorrhagia,  and  haemorrhage  from 
the  kidneys  and  intestines  ;  and  weakness  of  the  lower  ex- 
tremities is  a  not  unfrequent  symptom  of  chlorosis  and  severe 
acute  diseases. 

§  504.  Symptoms. — It  has  been  proved  experimentally  in 
animals  that,  when  the  aorta  is  compressed,  motor  and  sensory 
paralysis  of  the  lower  extremities  immediately  occurs,  the  reflex 
acts  cease,  and  the  bladder  and  rectum  are  paralysed.  When 
the  circulation  is  restored,  improvement  in  the  symptoms  is 
slow  in  proportion  to  the  duration  of  the  compression.  The 
same  symptoms  occur  in  man  after  embolism  of  the  aorta. 
Gull  observed  paralysis  to  occur  in  a  few  minutes  from  embolism 
of  the  abdominal  aorta  in  a  case  of  aneurism.  If  the  con- 
traction of  the  aorta  occurs  gradually,  the  symptoms  develop 
gradually,  and  are  less  severe  in  nature.  They  consist  of  a 
feeling  of  numbness  and  weakness  of  the  lower  extremities, 
which  become  easily  fatigued  on  slight  exertion.  Nothing  is 
known  of  the  symptoms  caused  by  ischsemia  of  the  cervical 
region  of  the  cord. 

Yaso- motor  ischsemia  or  ansemia  from  reflex  irritation  is 
characterised  by  the  same  kind  of  symptoms  as  those  caused 
by  aortic  obstruction,  although  they  are  much  less  severe  in  the 
former  than  in  the  latter.  In  vaso-motor  ischsemia  some  source 
of  peripheral  irritation  can  be  discovered,  and  the  paralytic 
symptoms  generally  disappear  if  the  source  of  irritation  can  be 
removed.  The  intensity  of  the  paralytic  symptoms  is  said  to 
vary  in  degree  according  to  the  severity  of  the  peripheral 
irritation. 

In  the  spinal  ansemia  produced  by  general  causes,  motor 
weakness,  tremor  on  the  slightest  exertion,  and  in  some  cases 
complete  paralysis  are  the  most  constant  symptoms.  These 
symptoms  begin  in  the  lower  extremities,  and  extend  to  the 
trunk  and  arms.     The  sensibility  is  usually  intact,  but  parses- 


312  VASCULAR  DISEASES   OF  THE 

thesise,  pain,  hypersesthesia,  and  even  slight  anaesthesia  may 
occasionally  be  present.  The  reflex  actions  are  often  exaggerated, 
and  the  sphincters  are  not,  as  a  rule,  affected.  It  is  said  that 
the  symptoms  improve  on  lying  down,  and,  on  the  contrary, 
are  made  worse  when  the  patient  assumes  the  erect  posture. 
The  paralytic  symptoms  are  associated  with  the  usual  signs  of 
general  ansemia  or  of  chlorosis. 

§  505.  Course,  Duration,  and  Termination. — The  disease 
may  begin  suddenly  when  it  is  caused  by  severe  hsemorrhage  or 
embolism,  but  the  onset  is  more  gradual  when  it  results  from 
thrombosis  and  chlorosis.  The  patient  often  recovers  rapidly 
by  the  establishment  of  collateral  circulation.  At  other  times 
recovery  is  slow  and  gradual,  and  in  cases  of  embolism  the  cord 
may  undergo  softening,  so  that  recovery  becomes  impossible. 

§  506.  Pathological  Anatomy. — Anaemic  portions  of  the 
cord  look  pale  and  bloodless.  The  grey  substance  is  dull  in 
colour,  and  sinks  below  the  level  of  section ;  while  the  white  is 
soft,  and  protrudes  slightly  above  the  surface  of  the  section. 
The  membranes  are  pale,  and  their  vessels  are  empty.  The 
anaemic  portions  contrast  strongly  in  colour  and  consistence  with 
those  which  are  healthy.  In  thrombosis  and  embolism  of  the 
small  spinal  vessels  it  is  often  possible  to  find  the  point  of 
occlusion.  Red  softening  exists  in  the  region  supplied  by  the 
plugged  artery  and  collateral  fluxion  in  its  vicinity.  If  the 
ischgemia  be  protracted,  white  and  yellow  softening  of  the  cor- 
responding portion  of  the  cord  may  occur. 

§  507.  Diagnosis. — The  diagnosis  must  rest  mainly  on  the 
concomitant  symptoms.  The  symptoms  of  the  acute  ischsemic 
form  resemble  those  due  to  spinal  haemorrhage,  and  anaemia 
can  only  be  inferred  to  be  the  cause  when  the  aorta  is  known  to 
be  obstructed  or  a  great  loss  of  blood  has  recently  occurred. 

The  chronic  forms  of  spinal  anaemia  resemble  chronic  myelitis 
or  chronic  meningitis,  but  when  severe  general  anaemia  exists 
it  may  be  inferred  that  the  disease  is  caused  by  it.  The  fact 
that  the  horizontal  position  relieves  the  symptoms  may  afford 
valuable  aid  in  forming  a  diagnosis  (Hammond). 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  313 

8  508.  Prognosis. — Spinal  ansemia  is  not  a  serious  disease 
taken  in  itself,  but  in  some  of  the  severer  cases  softening  may 
occur,  and  then  the  prognosis  becomes  unfavourable. 

§  509.  Treatment. — The  causes  of  anaemia  of  the  cord  must 
first  be  removed.  This  must  be  done  by  a  tonic  and  stimu- 
lating treatment. 

The  patient  should  be  laid  on  his  back  with  his  head  and 
legs  raised,  and  this  position  should  be  maintained  in  the  night 
and  for  a  considerable  portion  of  the  day. 

Special  stimulants  of  the  cord  itself  may  be  administered, 
the  most  powerful  and  reliable  of  them  being  strychnine.  The 
constant  current  should  be  applied  daily  to  the  vertebral  column, 
especially  in  the  form  of  the  ascending  stabile  current.  Warm 
applications  should  be  made  to  the  back,  such  as  hot  sand  bags, 
or  Chapman's  spinal  bags  filled  with  hot  water. 

The  diet  should  be  generous  and  moderately  stimulating. 

2.  Ancemia  of  the  Medulla  Oblongata — Thrombosis  and 
Embolism — Necrotic  Softening. 

§  510. — Ansemia  of  the  medulla  oblongata  is  generally  accom- 
panied by  ansemia  of  the  brain  and  spinal  cord.  Some  of  the 
symptoms,  however,  which  occur  in  general  ansemia  are  probably 
caused  by  ansemia  of  the  medulla  oblongata. 

Thrombosis  and  embolism  of  the  vessels  supplying  the  me- 
dulla are  not  very  rare,  and  the  anemia  in  such  cases  is  so  great 
that,  unless  the  circulation  be  quickly  restored,  the  part  soon 
undergoes  softening. 

Thrombi  and  er)iboli  generally  occur  in  the  vertebral  and 
basilar  arteries  (§§  353,  354).  This  subject  has  received  much 
attention  in  recent  years,  and  in  consequence  cases  which  were 
at  one  time  classed  together  as  apoplectic  bulbar  paralysis  are 
now  known  to  have  been  produced  by  embolism  or  thrombosis 
of  the  arteries  of  the  medulla  oblongata. 

§  511.  Symptoms. — The  symptoms  of  simple  ansemia  of  the 
medulla  do  not  require  to  be  separately  considered,  as  they  are 
merged  in  the  symptoms  of  ansemia  of  the  cord. 


314  VASCULAR  DISEASES   OF   THE 

The  symptoms  produced  by  obstruction  of  the  arteries  differ 
according  as  the  main  arteries  or  the  small  branches  are  affected. 

The  following  general  symptoms  are  commonly  observed 
when  one  or  both  vertebral  arteries,  or  the  basilar  artery,  are 
obstructed  by  thrombosis  or  embolism.  A  more  or  less  complete 
bulbar  paralysis  occurs  suddenly  or  in  a  very  short  time,  and 
without  loss  of  consciousness.  The  soft  palate  and  tongue  are 
paralysed,  the  power  of  articulation  and  of  deglutition  is  lost, 
and  there  is  partial  paralysis  of  the  muscles  supplied  by  the  in- 
ferior portion  of  the  facial  nerve.  These  symptoms  are  some- 
times accompanied  by  paralysis  of  the  ocular  and  masticatory 
muscles,  dulness  of  hearing,  and  noises  in  the  ears.  Respiratory, 
circulatory,  and  vocal  disorders  are  also  of  frequent  occurrence. 
Paralysis  of  one  or  all  of  the  extremities  is  simultaneously 
developed.  As  a  rule,  a  certain  degree  of  anaesthesia  is 
present. 

If  death  from  respiratory  paralysis  does  not  at  once  ensue, 
the  disease  is  not  of  a  progressive  character,  and  at  most  only 
a  slight  change  for  the  worse  takes  place  during  the  first  few 
days. 

In  some  cases  gradual  improvement  may  take  place,  the 
paralysis  partially  disappears,  the  muscles  of  the  extremities 
undergo  various  degrees  of  contracture,  and  the  tendon  reflexes 
are  exaggerated,  but  life  may  be  preserved  for  a  comparatively 
long  period. 

§  512.   Varieties.   ' 

(1)  Obstruction  of  the  basilar  arUry,  as  a  rule,  produces  bilateral  symp- 
toms, paralysis  of  all  four  extremities,  and  of  both  sides  of  the  face.  But  the 
most  important  symptom  is  the  cessation  of  the  functions  of  the  vagus  and 
glosso-pharyngeal  nuclei,  causing  severe  respiratory  disorders,  dyspncEa, 
cyanosis,  and  usually  a  rapid  death  from  asphyxia.  A  rapid  and  complete 
obstruction  of  the  basilar  artery  generally  produces  profound  coma  and  rapid 
death.  If  life  last  for  a  few  hours  complete  paralysis  of  all  four  extremities 
is  observed. 

(2)  If  the  obstnbction  extend  only  to  a  small  portion  of  the  basilar,  or  if 
the  thrombosis  be  merely  attached  to  the  walls  of  the  vessel  and  only  cut 
oflf  the  blood  from  a  few  branches,  the  symptoms  are  often  less  threatening. 
Individual  cranial  nerves  are  paralysed,  and  there  is  weakness  or  paralysis 
of  the  extremities  ;  some  of  the  ocular  muscles  may  be  paralysed,  as  well 
as  those  supplied  by  the  facial  and  trigeminal  nerves.     If,  however,  the 


SPINAL   CORD  AND   MEDULLA  OBLONGATA.  315 

circulation  continue  in  the  posterior  portion  of  the  basilar  artery  and  in 
the  vertebral  arteries,  respiration  is  not  arrested. 

(3)  SimuUaneoiis  obstruetio7i  of  both  vertebral  arteries  produces  exactly 
the  same  effects  as  thrombosis  of  the  basilar  artery.  The  life  of  the  patient 
is  not  in  such  immediate  danger  if  the  thrombosis  be  slowly  developed  so 
as  to  allow  time  for  collateral  circulation  to  be  established.  Joffroy 
attaches  some  importance  to  the  lockjaw  which  has  been  observed  in  such 
cases. 

(4)  Obliteration  of  one  vertebral  artery  produces  symptoms  which  assume 
to  some  extent  the  hemiplegic  form.  The  lesion  is  more  frequent  in  the 
left  artery,  from  which  the  anterior  spinal  artery  is  often  exclusively  or  in 
great  part  given  off.    The  inferior  cerebellar  artery  is  also  obstructed. 

The  hemiplegia  may  either  be  on  the  same  side  as  the  lesion  or  on  the 
opposite  side,  a  matter  that  depends  on  variable  conditions,  such  as  the 
situation  of  the  obstruction,  the  point  of  origin  of  the  anterior  spinal 
artery,  the  completeness  of  the  decussation  of  the  anterior  pyramids,  and 
other  circumstances.  The  hypoglossal  and  spinal  accessory  nerves  may  be 
paralysed,  causing  disorders  of  articulation  and  deglutition  and  aphonia, 
and  in  addition  there  may  be  paralysis  of  the  inferior  branches  of  the  facial, 
and  partial  paralysis  and  anaesthesia  of  the  soft  palate.  These  symptoms 
may  be  to  some  extent  bilateral,  but  are  generally  more  pronounced  on  one 
side  of  the  body. 

The  successive  occlusion  of  the  different  arterial  territories  may  be 
recognised  by  the  grouping  of  the  symptoms  and  the  order  in  which  they 
follow  one  another. 

The  larger  the  vessel  obstructed,  and  the  more  complete  the  occlusion, 
the  quicker  does  death  ensue.  If  the  circulation  can  be  quickly  restored 
by  the  disintegration  or  displacement  of  the  thrombus  or  embolus,  or  by 
sufficient  collateral  branches,  improvement  in  the  symptoms  and  partial 
recovery  may  take  place. 

(5)  Occlusion  of  the  small  arteries  of  the  medulla  oblongata  can 
never  be  diagnosed  with  certainty  from  the  symptoms.  But  as  these 
vessels  are  terminal  their  obliteration  is  surely  followed  by  necrosis  of 
the  parts  affected,  and  it  only  depends  on  the  territory  of  such  artery 
whether  we  get  symptoms  or  not.  Obstruction  of  the  smaller  vessels 
may  produce  partial  paralysis  of  the  tongue,  difficulties  of  articulation  and 
swallowing,  unilateral  paralysis  of  the  facial  and  abducens  nerves,  respira- 
tory disorders,  and  perhaps  even  fits  of  asthma. 

(6)  Obstruction  of  the  superior  cerebellar  artery  produces  paralysis  of  the 
third  nerve  on  the  side  of  the  occluded  vessel  and  hemiplegia  of  the 
opposite  side. 

§  513.  Morbid  Anatomy. — Either  one  or  both  vertebral 
arteries  may  be  completely  obliterated,  and  the  thrombosis  may 
extend  from  them  into  the  basilar  artery.     The  basilar  artery 


316  VASCULAR  DISEASES   OF  THE 

may  be  obstructed,  either  from  one  end  to  the  other  or  for  a 
short  distance  in  its  anterior,  median,  or  posterior  division,  and 
any  one  or  all  of  the  branches  given  off  from  the  main  arteries 
may  be  partially  or  wholly  obstructed  by  thrombosis. 

Most  of  the  arteries  of  the  medulla  oblongata  are  terminal 
arteries,  hence  obstruction  of  one  of  them  always  occasions 
grave  disorders  of  nutrition.  The  immediate  result  is  to  pro- 
duce intense  ansemia  in  the  vascular  territory  affected.  The 
second  stage  consists  of  engorgement,  accompanied  by  effusion  of 
blood  (hsemorrhagic  infarct),  which  leads  to  red  and  afterwards 
yellow  and  white  softening.  The  final  stage  often  consists  in 
the  formation  of  a  cavity  of  variable  size  in  the  medulla.  The 
walls  of  the  cavity  are  formed  of  a  soft  reticular  connective 
tissue,  while  delicate  threads  of  the  same  traverse  the  interior. 

If  the  obstruction  take  place  in  one  of  the  smaller  vessels,  a 
number  of  small  wedge-shaped  centres  of  softening  or  hsemor- 
rhagic infarcts  are  found,  having  their  apices  directed  forwards 
and  their  bases  towards  the  floor  of  the  fourth  ventricle. 

§  514.  Diagnosis. — When  a  bulbar  paralysis,  accompanied 
either  by  hemiplegia  or  paraplegia  of  the  extremities,  occurs 
suddenly,  our  attention  should  at  once  be  directed  to  the  pons 
and  medulla  oblongata.  In  fulminant  and  extremely  rapid 
cases,  when  the  patient  sinks  into  deep  coma  and  universal 
paralysis  sets  in  with  threatening  asphyxia,  we  can  only  make 
a  guess  with  regard  to  the  nature  and  situation  of  the  lesion. 

Even  when  it  is  possible  to  determine  that  the  lesion  has 
occurred  in  the  medulla  oblongata,  it  is  not  always  easy  to 
decide  whether  a  haemorrhage  or  an  embolus  has  taken  place, 
and  the  question  must  be  determined  from  general  considera- 
tions. When  the  symptoms  come  on,  one  after  another  and 
not  all  at  once,  obstruction  of  a  vessel  must  be  presumed. 
Epileptoid  convulsions  are  more  frequent  in  haemorrhage 
than  in  embolus  and  thrombosis.  It  is  only  when  the  basilar 
is  completely  occluded  that  we  meet  with  a  severe  apoplectic 
attack. 

The  symptoms  of  embolism  are  often  of  a  definite  character, 
owing  to  the  regular  distribution  of  the  vessels ;  whilst  those  of 
apoplexy  are  more  dependent  on  chance,  so  that  we  meet  with 


SPINAL   CORD  AND  MEDULLA  OBLONGATA,  317 

a  repetition  of  exactly   the    same  group  of  symptoms   more 
frequently  in  cases  of  embolus  than  we  do  in  extravasation. 

Striking  and  rapid  improvement,  with  total  disappearance  of 
complete  groups  of  paralytic  symptoms,  seldom  occurs  in  cases 
of  haemorrhage.  The  frequent  anomalous  distribution  of  the 
vessels  often  renders  it  impossible  to  diagnose  the  particular 
artery  which  has  been  obstructed.  Other  symptoms  may  help 
us  to  a  diagnosis.  An  unusually  full  pulse  in  the  carotids  is 
said  to  point  to  obstruction  of  the  basilar  artery. 

§  515.  Prognosis. — The  prognosis  is  always  of  the  gravest 
character,  and  sudden  and  complete  obstruction  of  the  basilar  or 
of  both  vertebral  arteries  is  almost  invariably  fatal.  A  slowly- 
developing  occlusion  of  one  or  more  of  the  large  vessels  in  this 
region  also  terminates  in  death  within  a  short  period.  Life 
may  be  prolonged  and  partial  recovery  take  place  in  cases  of 
relatively  limited  obstruction  which  happen  to  affect  the  least 
dangerous  parts  of  the  medulla,  or  when  a  considerable  collateral 
circulation  is  established. 

§  516.  Treatment' — Stimulants  and  tonics  are  plainly  in- 
dicated when  one  of  the  bulbar  arteries  are  obstructed ;  but 
unfortunately  the  diagnosis  is  so  uncertain  in  many  cases  that 
it  is  difficult  to  follow  out  any  definite  course  of  treatment. 
At  a  later  period  electricity  may  be  applied  with  the  greatest 
hope  of  success. 

(U.)  HYPEREMIA  AND  H^MORKHAGE    OF  THE  SPINAL  CORD 
AND  MEDULLA  OBLONGATA. 

1.  Hypercemia  of  the  Spinal  Cord  and  its  Membranes. 

§  517.  It  is  impossible  to  separate  hypersemia  of  the  spinal 
cord  and  of  the  spinal  membranes,  either  clinically  or  anato- 
mically, hence  the  two  must  be  considered  together.  By  hyper- 
emia of  the  cord  and  its  membranes,  therefore,  is  understood 
an  increased  supply  of  blood  in  the  structures  contained  within 
the  vertebral  canal. 

§  518.  Etiology. — HypersBmia  of  the  cord  is  produced  by 
excessive  functional  activity,  such  as  occurs  in  severe  exertion 


318  VASCULAR  DISEASES   OF  THE 

or  violent  sexual  excitement.  Congestion  is  also  present  in  the 
early  stages  of  inflammation  of  the  cord,  so  that  all  the  causes 
of  myelitis  are  likewise  causes  of  hypersemia  of  the  cord. 
Hypersemia  of  the  spinal  cord  may  also  be  caused  by  various 
toxic  agents,  such  as  strychnia,  carbonic  oxide,  and  alcoholic 
excess.  Exposure  to  cold  is  probably  the  most  common  cause 
of  spinal  hypersemia,  but  it  may  be  produced  by  the  suppression 
of  accustomed  discharges,  and  by  concussion  and  traumatic 
injuries  of  the  vertebral  column,  while  it  is  a  frequent  sequel  of 
the  specific  fevers  and  malarial  infection. 

Passive  hypersemia  is  generally  caused  by  the  conditions 
which  favour  general  venous  congestion  or  stasis,  such  as 
diseases  of  the  heart  and  lungs,  or  diseases  like  tetanus  and 
eclampsia. 

§  519.  Symptoms. — The  most  prominent  symptoms  of  spinal 
hypersemia  are  pains  in  the  loins  and  along  the  spine  of  a  dull, 
oppressive  character,  which  are  not  increased  on  pressure.  The 
patient  complains  of  tingling,  formication,  and  tearing  pains  in 
the  lower  extremities,  and  a  slight  degree  of  hypersesthesia  of 
the  skin,  a  girdle  sensation,  and  a  moderate  increase  of  reflex 
activity  may  be  present.  The  motor  symptoms  consist  of 
transitory  jerking  of  the  muscles  and  trembling  of  the  limbs, 
and  Rosenthal  says  that  the  electrical  excitability  is  increased. 

Depressive  symptoms  may  likewise  appear  at  an  early  period 
of  the  disease.  A  sensation  of  numbness  is  felt  in  the  lower 
extremities  and  there  may  be  also  a  slight  degree  of  ansesthesia. 

The  patient  complains  of  fatigue  on  slight  exertion,  the  limbs 
feel  heavy  and  feeble,  but  it  is  probable  that  complete  para- 
plegia never  occurs  in  simple  hypersemia. 

Paresis  of  the  bladder  is  rare,  but  has  been  occasionally  met 
with,  and  Hammond  has  observed  erection  of  the  penis. 

The  symptoms  are  almost  always  bilateral  and  are  limited  to 
the  lower  half  of  the  body,  or  at  least  they  begin  in  the  lower 
extremities.  Occasionally  the  affection  may  extend  to  the  upper 
extremities,  and  in  those  cases  the  respiration  is  said  to  have 
been  disturbed. 

Brown-Sdquard  says  that  the  symptoms  are  aggravated  by 
lying  on  the  back,  with  the  head  and  legs  raised,  while  they 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  319 

are  relieved  by  lying  on  the  face  or  by  standing  or  walking, 
and  the  patients  are  also  said  to  feel  worse  in  the  morning 
while  in  bed.  When  serous  effusion  has  taken  place,  it  collects 
in  the  lower  part  of  the  spinal  canal  on  the  patient  assuming 
the  erect  posture,  and  consequently  the  patients  are  then  better 
in  the  horizontal  position.  There  is  no  fever,  and  the  pulse  may 
be  either  quick  or  slow  if  the  hypera^mia  extend  to  the  spinal 
centres  of  cardiac  innervation.  The  general  health  suffers  to  a 
greater  or  lesser  degree. 

It  is  very  difficult  to  distinguish  between  active  and  passive 
hypersemia,  but  if  the  irritative  phenomena  predominate,  it 
may  be  presumed  that  the  case  is  one  of  active  hypersemia ; 
and  if  depressive  symptoms  predominate,  that  it  is  one  of 
passive  hypersemia. 

§  520.  Course. — The  development  is  at  times  sudden,  and 
then  the  disease  runs  through  an  acute  course,  and  is  soon 
terminated.  At  other  times  the  course  of  the  affection  is  slow  ; 
it  gradually  increases  in  severity,  and  then  continues  for  days, 
weeks,  or  months,  with  varying  degrees  of  intensity.  The  disease 
generally  ends  in  recovery,  but  relapses  are  not  rare.  Recovery 
is  often  favoured  by  critical  haemorrhages.  It  is  probable  that 
simple  hypersemia  never  ends  fatally. 

§  521.  Diagnosis. — The  diagnosis  of  hyperemia  of  the  struc- 
tures within  the  spinal  canal  is  based  on  the  slight  and  transi- 
tory nature  of  the  sensory  and  motor  disturbances,  and  upon 
the  frequent  and  rapid  changes  in  the  symptoms,  the  absence 
of  increase  of  temperature,  the  short  and  favourable  course  of 
the  symptoms,  and  the  success  of  treatment  calculated  to  relieve 
congestion. 

Concussion  of  the  cord  may  be  distinguished  from  hypersemia 
by  the  history  of  an  injury. 

In  spinal  meningitis  the  prominent  symptoms  are  spasm  of 
the  back  and  neck,  pain  on  moving  the  limbs,  and  high  fever — 
symptoms  which  are  absent  in  simple  hypersemia. 

Acute  myelitis  may  be  recognised  by  the  presence  of  fever, 
severe  paralytic  symptoms,  contractures,  paralysis  of  the 
bladder,  and  bed-sores. 


320  VASCULAE  DISEASES   OF  THE 

Spinal  apoplexy  begins  suddenly,  the  paralytic  symptoms 
are  severe,  and  more  or  less  lasting. 

Spinal  ancemia  is  distinguished  from  hypersemia  by  the  fact 
that  lying  on  the  back  gives  relief  to  the  symptoms  of  the 
former,  while  they  aggravate  those  of  the  latter. 

§  522.  Prognosis. — The  prognosis  is  on  the  whole  favourable; 
but  the  affection,  if  unchecked,  is  liable  to  cause  haemorrhage 
or  inflammation  of  the  cord,  and  then  the  prognosis  becomes 
serious. 

§  523.  Morbid  Anatomy. — After  death  the  arteries  con- 
tract and  empty  their  contents  into  the  veins,  so  that  even  when 
active  hypersemia  has  existed  during  life  it  may  occasion  no  cha- 
racteristic appearances  after  death ;  while,  on  the  other  hand, 
vessels  may  become  much  congested  in  consequence  of  a  pro- 
longed death  struggle,  or  of  hypostatic  congestion  after  death. 
In  active  hypersemia  the  grey  substance  often  appears  of  a  rose 
or  scarlet  colour,  and  the  white  substance  of  a  reddish  tinge, 
the  blood-vessels  are  tortuous  and  congested,  and  on  microscopic 
examination  the  smaller  arteries  and  capillaries  are  seen  to  be 
enlarged  and  unusually  distended  with  blood.  In  severe  cases 
punctiform  extravasations  and  ecchymoses  may  be  seen  dotted 
over  the  membranes,  and  in  the  substance  of  the  cord.  The 
spinal  fluid  is  usually  increased  in  quantity,  and  is  of  a  muddy 
or  reddish  colour  (Erb). 

In  passive  hypersemia  the  extra-meningeal  plexuses  of  veins 
are  especially  distended  with  blood ;  the  individual  veins  are 
enlarged  and  tortuous,  and  the  whole  cord  presents  a  dark 
blue  colour.  The  spinal  fluid  is  almost  always  increased,  and 
ecchymoses  may  also  be  present. 

In  chronic  and  frequently-repeated  hypersemia  the  pia  mater 
and  arachnoid  are  thickened  and  opaque,  and  highly  pigmented. 

§  524.  Treatment. — The  most  favourable  cases  of  active 
hypersemia  are  those  which  arise  from  the  suppression  of  a 
habitual  discharge  or  from  exposure  to  cold.  The  patient 
should  be  directed  to  lie  on  the  side  or  face,  with  the  extremities 
as   low  as  possible.     Venesection  may  be  practised  in  robust 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  321 

persons  when  the  symptoms  are  violent,  but  as  a  rule  it  is 
preferable  to  draw  blood  by  leeching.  The  leeches  may  be 
applied  to  the  region  of  the  spinal  column,  anus,  vagina,  or 
cervic  uteri,  according  to  the  nature  of  the  case. 

I  have  seen  an  aggravated  case  of  spinal  hypersemia  recover 
in  a  few  days  under  the  care  of  my  colleague.  Dr.  Simpson. 
The  treatment  consisted  in  the  application  of  Chapman's  ice- 
bags  to  the  spine,  while  the  patient  was  ordered  to  lie  with 
his  face  directed  downwards.  The  application  of  cold  affusions 
and  douches,  cold  packing,  and  sea  baths  may  take  the  place  of 
the  ice-bag. 

A  saline  purgative  may  be  of  use  by  unloading  the  vessels 
and  lowerinsf  arterial  tension.  Ergotin  and  belladonna  are  the 
favourite  internal  remedies,  but  it  is  very  .doubtful  how  far  they 
are  of  use. 

The  diet  should  be  plain  and  nourishing,  but  unstimulating, 
and  everything  which  might  increase  the  hypersemia,  such  as 
sexual  and  alcoholic  indulgence,  must  be  avoided. 

2.  Hcemorrhage  into  the  Substance  of  the  Spinal  Cord. 

Hcematomyelia — Spinal  Apoplexy. 

§  525.  Definition. — Spinal  apoplexy  consists  of  btemorrhage 
into  the  substance  of  the  cord. 

§  52G.  Etiology. — Contrary  to  what  occurs  in  cerebral  disease, 
spinal  apoplexy  is  more  common  in  youth  and  middle  age  than 
in  old  age.  Men  are  more  subject  to  the  affection  than  women. 
Chronic  affections  of  the  cord  are  often  brought  to  a  sudden 
close  by  haemorrhage,  owing  doubtless  to  coincident  changes 
occurring  in  the  walls  of  the  vessels.  Amongst  the  exciting 
causes  are  traumatic  injuries,  active  congestion  of  the  cord,  and 
anything  that  produces  a  want  of  equilibrium  between  the 
pressure  within  and  without  the  blood-vessels.  It  is  doubtful 
how  far  excessive  cardiac  action  in  the  absence  of  degeneration 
of  the  vessels  can  give  rise  to  haemorrhage.  Hsemorrhage  may 
occur  in  connection  with  tumours,  or  any  morbid  process  which 
occasions  softening  of  the  substance  of  the  cord. 

§  527.  Symptoms. — The  attack   generally  begins  suddenly 
V 


822  VASCULAR  DISEASES  OF  THE 

with  fulminant  symptoms.  The  patient  complains  of  violent 
pains,  and  becomes  suddenly  paraplegic,  but  without  loss  of 
consciousness.  The  disease  may  be  preceded  by  premonitory 
symptoms,  consisting  either  of  those  indicative  of  spinal  conges- 
tion or  of  the  symptoms  which  precede  acute  central  myelitis, 
and  these  may  last  from  a  few  hours  or  several  days.  But 
even  in  the  cases  in  which  the  affection  is  preceded  by  pre- 
monitory symptoms,  the  onset  of  the  characteristic  symptoms 
is  always  sudden,  and  complete  paraplegia  develops  in  the 
course  of  a  few  minutes,  or  at  most  an  hour.  During  the 
development  of  the  paralysis  the  patient  complains  of  violent 
pain,  either  localised  or  extending  over  the  entire  spinal  column, 
but  usually  disappearing  when  the  paralysis  has  become  com- 
plete. When  the  cervical  region  is  implicated,  the  paraplegia 
extends  to  the  upper  extremities,  the  respiratory  muscles  are 
affected,  and  the  patient  breathes  laboriously  by  the  aid  of  the 
diaphragm. 

The  paralysed  muscles  are  flaccid,  and  more  or  less  complete 
anaesthesia  of  every  form  of  cutaneous  sensibility  having  the 
same  distribution  as  the  motor  paralysis  is  present.  Paralysis 
of  the  rectum  and  bladder  occurs ;  at  first  there  is  retention  of 
urine  and  afterwards  various  degrees  of  incontinence. 

Vaso-motor  disturbances  are  generally  present.  Levier  found 
the  temperature  of  the  paralysed  extremities,  as  compared  with 
that  of  the  axilla,  increased  from  0*2°  to  2°0  C. 

The  reflex  actions  vary  much  according  to  the  seat  of  the 
lesion.  When  the  grey  matter  is  infiltrated  down  to  its  lowest 
point,  they  are  completely  abolished.  When  the  seat  of  the 
haemorrhage  is  higher  up,  reflex  actions  disappear  for  a  short 
time,  owing  to  the  shock ;  but  they  may  afterwards  reappear  in 
an  exaggerated  form.  In  most  cases,  however,  the  reflex  actions 
disappear  after  a  time.  Priapism  is  mentioned  as  a  symptom 
in  a  few  cases.  The  paralysed  muscles  undergo  atrophy,  they 
lose  their  faradic  excitability,  and  manifest  the  reaction  of 
degeneration.  At  a  later  period,  when  secondary  changes 
occur  in  the  cord,  a  few  of  the  muscles  may  become  rigid  and 
contracted.  The  symptoms  of  secondary  myelitis  may  be  super- 
added and  give  rise  to  violent  pains,  twitching  movements  and 
jerkings  of  the  extremities,  and  the  formation  of  contractures. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  323 

Throughout  the  whole  course  of  the  disease  symptoms  of 
motor  irritation  are  almost  entirely  absent.  During  the  first 
moments  of  the  hsemorrhage  slight  muscular  twitching  and 
partial  spasms  may  occur,  but  these  phenomena  soon  give 
place  to  paralysis.  Spasmodic  symptoms  may  also  occur  at  a 
later  period,  but  they  are  caused  by  secondary  degeneration. 
Tingling  and  other  parsesthesise  may  occasionally  be  felt  in  the 
paralysed  parts,  but,  as  a  rule,  these  symptoms  are  wholly 
absent,  and  the  patients  do  not  feel  their  limbs. 

After  a  few  days  or  weeks,  according  to  the  severity  of  the 
case,  gangrenous  bed-sores  appear  on  the  sacrum,  trochanters, 
heels,  and  other  places  exposed  to  pressure.  Paralysis  of  the 
bladder  leads  to  alkalescence  of  the  urine,  cystitis,  pyelitis,  and 
their  sequelee,  and  the  patient  dies  in  a  state  of  great  marasmus. 

The  symptoms,  of  course,  vary  greatly  according  to  the 
cause,  extent,  and  situation  of  the  hsemorrhage.  In  small 
haemorrhages  the  symptoms  are  so  destitute  of  any  dis- 
tinguishing features  as  to  render  the  diagnosis  a  matter  of 
great  uncertainty.  When  the  hsemorrhage  is  limited  to  the 
anterior  cornua,  the  symptoms  produced  will  be  mainly  those 
of  local  paralysis  ;  while  if  it  be  limited  to  the  posterior  cornua, 
the  symptoms  will  be  extremely  indefinite. 

If  the  lumbar  region  of  the  cord  be  affected,  the  symptoms 
of  paralysis  and  ansesthesia  are  restricted  to  the  lower  extremi- 
ties, bladder,  and  rectum;  reflex  actions  are  absent,  and  rapid 
atrophy  of  the  muscles  and  bed-sores  occur  at  an  early  period 
of  the  disease. 

If  the  dorsal  region  be  affected,  the  paralysis  extends  higher 
up.  The  expiratory  muscles  and  those  which  compress  the 
abdomen  are  paralysed,  but  reflex  actions  may  be  retained  for 
a  long  time,  and  atrophy  of  the  muscles  is  slow. 

If  the  cervical  region  be  implicated,  all  the  four  extremities 
are  affected,  a  portion  of  the  inspiratory  muscles  are  paralysed, 
oculo-pupillary  symptoms  may  be  present,  and  the  implication 
of  the  reflex  processes  and  nutrition  depend  on  the  downward 
progress  of  the  lesion.  If  the  hsemorrhage  occur  above  the 
origin  of  the  phrenic  nerve,  rapid  death  by  asphyxia  is  inevitable. 
In  a  few  cases  the  hsemorrhage  has  been  found  limited  to  one 
half  of  the  cord. 


324  VASCULAR  DISEASES  OF  THE 

§  528.  Course,  Duration,  and  Termination. — The  course 
depends  on  the  cause  of  the  disease  and  the  extent  and  locality 
of  the  heemorrhage.  In  severe  cases  of  diffuse  central  bleeding 
a  fatal  termination  occurs  soon  through  paralysis  of  respiration, 
or  death  results  from  acute  bed-sores,  pyaemia,  and  septicaemia. 
If  the  haemorrhage  be  small  the  case  may  be  very  protracted, 
but  death  ultimately  results  from  bed-sores,  cystitis,  fever, 
marasmus,  and  other  complications. 

The  lesion  in  the  cord  sometimes  cicatrises,  and  partial 
recovery  occurs  even  after  cystitis  and  bed-sores  have  made 
their  appearance ;  but  in  these  cases  some  muscles  or  group  of 
muscles  usually  remain  paralysed  and  atrophied.  Complete 
recovery  is  only  possible  when  the  clot  is  small. 

The  duration  of  the  disease  varies  greatly.  Rapid  cases 
terminate  in  a  few  minutes,  hours,  or  days  ;  while  in  less  severe 
ones,  weeks,  months,  or  even  years  may  elapse  before  death 
occurs. 

§  529.  Morbid  Anatomy. — The  bleeding  is  generally  limited 
to  the  grey  substance,  and  may  involve  the  cornua  or  the  entire 
grey  substance,  and  may  extend  to  various  distances  longitu- 
dinally. Two  kinds  of  extravasation  may  occur :  the  haemor- 
rhagic  or  apoplectic  clot,  and  the  haemorrhagic  infiltration  or 
softening. 

The  hmmorrhagic  or  apoplectic  clot  varies  in  size  from  that 
of  a  pea  to  that  of  a  hazel-nut,  and  its  longitudinal  is  generally 
longer  than  its  transverse  diameter.  The  clot  is  often  seen 
through  the  pia  mater  as  a  bluish  nodule,  while  the  pia  is 
sometimes  ruptured,  so  that  blood  makes  its  way  into  the 
subarachnoidal  space.  The  clot  is  surrounded  by  ragged  walls 
formed  by  disintegrated  nerve  tissue.  The  haemorrhage  may 
pass  for  a  considerable  distance  between  the  bundles  of  white 
fibres,  and  a  large  portion  of  the  grey  substance  may  be  de- 
stroyed, giving  rise  to  what  is  called  a  "  tubular  haemorrhage." 
The  portions  of  the  cord  most  usually  affected  are  the  cervical 
and  upper  dorsal  regions. 

The  clot  after  a  time  undergoes  a  series  of  further  changes. 
It  either  slowly  dries  up  to  a  crumbly,  caseous  mass  of  a  dark 
colour,  containing  crystals  of  haematoidin,  or  undergoes  a  pro- 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  325 

cess  of  softening,  with  subsequent  absorption,  so  that  at  last  a 
capsule  of  connective  tissue  is  left,  filled  only  with  a  serous 
fluid.  When  the  extravasation  is  small  it  may  be  absorbed,  so 
as  to  leave  only  a  small  cicatrix  of  connective  tissue. 

Secondary  disease  of  the  cord  is  very  often  found  in  the 
neighbourhood  of  the  clot.  This  generally  consists  of  softening, 
which  extends  to  a  variable  distance  both  upwards  and  down- 
wards. The  grey  matter  often  undergoes  hsemorrhagic  softening, 
and  is  sometimes  converted  into  a  softened  mass  of  a  reddish 
black  or  chocolate  colour,  while  white  softening  may  be  observed 
in  the  neighbourhood  of  the  clot.  In  old-standing  cases  secondary 
ascending  and  descending  sclerosis  occurs. 

Hcemorrhagic  infiltration  or  softening  occurs  in  the  grey 
substance  exclusively.  It  is  limited  to  one  or  more  of  the  grey 
horns,  or  extends  over  the  whole  of  the  grey  matter,  but  rarely 
spreads  to  the  white  substance.  It  may  extend  longitudinally 
a  few  centimetres  only,  or  the  whole  length  of  the  cord.  The 
grey  substance  is  changed  into  a  reddish-brown  mass  dotted 
with  dark  red  points.  The  microscope  shows  elements  like 
those  in  the  clot,  but  with  the  addition  of  granular  corpuscles 
and  degenerative  changes  in  the  nerve  fibres  and  ganglion  cells. 

The  usual  evidences  of  acute  central  myelitis  may  be  observed 
far  beyond  the  limits  of  the  hsemorrhagic  infiltration. 

§  530.  Diagnosis. — The  diagnosis  is  chiefly  based  on  the 
sudden  and  very  rapid  invasion  of  paraplegia  without  much 
irritation,  and  the  immediate  severity  of  the  symptoms.  It  is 
distinguished  from  cerebral  apoplexy  by  the  retention  of  con- 
sciousness, the  absence  of  all  symptoms  of  paralysis  of  cerebral 
nerves,  the  paraplegic  form  assumed  by  the  paralysis,  and  by 
the  presence  of  paralysis  of  the  sphincters. 

In  meningeal  hcBinorrhage  there  are  active  symptoms  of  irrita- 
tion, hypersesthesia  and  pain,  violent  spasms,  while  paralysis  is 
less  prominent,  the  disturbances  of  sensibility  are  slight,  and 
the  course  of  the  attack  is  rapid  and  comparatively  favourable. 

Acute  central  myelitis  is  very  similar  in  its  symptoms  to 
spinal  apoplexy.  In  myelitis  the  paraplegia  requires  hours  or 
days  for  development.  It  begins  with  symptoms  of  irritation, 
such  as  pain  and  slight  spasm,  the  vertebral  column  is  sensitive 


326  VASCULAR  DISEASES  OF  THE 

to  pressure,  fever  may  be  present,  and  ansesthesia  and  par- 
sesthesise  are  prominent  symptoms,  while  partial  paralysis  and 
weakness  of  the  bladder  precedes  the  occurrence  of  severe 
paraplegia.  The  ascending  progress  of  central  myelitis  may 
be  contrasted  with  the  stationary  nature  of  the  symptoms  in 
haemorrhage. 

Poliomyelitis  anterior  acuta  in  adults  is  often  like  hsemato- 
myelia.  It  may  be  distinguished  by  the  presence  of  fever  at 
the  commencement,  the  absence  of  sensory  disturbances,  and  of 
palsy  of  the  bladder  and  bed-sores. 

The  ischcemic  paraplegia  caused  by  embolism  of  the  aorta 
can  alone  be  mistaken  for  hemorrhage,  and  this  accident  may  be 
recognised  by  absence  of  the  femoral  pulse  and  other  attendant 
symptoms. 

§  531.  Prognosis. — The  prognosis  is  always  grave.  Large 
central  hemorrhages  and  those  which  are  seated  at  a  high  level 
are  necessarily  fatal.  The  prognosis  becomes  more  hopeful  if  the 
first  few  days  and  weeks  pass  without  bringing  severe  compli- 
cations, but  complete  recovery  is  rarely  to  be  expected.  Small 
circumscribed  hsemorrhages  are  less  dangerous,  but  it  is  rare 
that  the  diagnosis  of  such  cases  amounts  to  anything  like 
certainty. 

§  532.  Treatment.  —  Prophylactic  treatment  should  be 
adopted,  such  as  removing  retained  or  suppressed  menses,  or 
alleviating  heart  disease  and  congestion  of  the  cord.  When 
the  symptoms  are  related  to  a  central  myelitis,  a  very  active 
antiphlogistic  treatment  should  be  adopted.  Chapman's  ice- 
bag  should  be  applied  to  the  back,  but  after  the  acute  stage 
is  over  a  more  stimulating  treatment  may  be  adopted.  For 
the  haemorrhage  itself  little  can  be  done  beyond  relieving  the 
congestion  of  the  cord  by  the  employment  of  local  bleeding, 
free  application  of  ice,  and  maintenance  of  the  horizontal 
position  upon  the  side  or  abdomen,  with  the  internal  use  of 
digitalis  or  ergot,  purgatives,  and  application  of  warmth  to  the 
extremities. 

Trophic  disturbances,  cystitis,  and  bed-soreg  must  be  sub- 
jected to  the  usual  treatment.     If  the  first  weeks  pass  without 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  327 

serious  results,  iodide  of  potassium  may  be  administered  to 
promote  absorption.  Warm  spring  and  brine  baths,  or  a 
moderate  hydropathic  treatment,  and  the  constant  current  may 
all  be  occasionally  of  use. 

3.  Hyp^rmmia  and  Hcemorrhage  of  the  Medulla  Oblongata. 
§  533.  Hypersemia  strictly  limited  to  the  medulla  must  be 
an  extremely  rare  occurrence,  and  in  the  majority  of  cases  it  is 
nothing  more  than  part  of  a  general  hypersemia  of  the  brain  or 
spinal  cord. 

§  534.  Hcemorrhage  of  the  medulla  is  more  closely  related 
to  the  vascular  diseases  of  the  brain  than  to  those  of  the  cord, 
and  the  frequency  of  the  occurrence  of  haemorrhage  is  greater  in 
the  cerebral  than  in  the  spinal  end  of  the  medulla.  Rupture 
of  a  vessel  is  on  the  whole  a  rare  occurrence  in  the  pons  and 
medulla  oblongata.  The  pathology  of  haemorrhage  of  the 
medulla  is  the  same  generally  as  that  of  hgemorrhage  of  the 
cord.  Disease  of  the  vessels,  such  as  miliary  aneurisms, 
atheroma,  fatty  degeneration,  and  capillary  dilatation  resulting 
from  processes  of  softening,  is  the  most  important  con- 
dition which  leads  to  the  production  of  haemorrhage.  Cases 
of  atheroma  and  aneurism  of  the  basilar  artery  are  often 
accompanied  by  haemorrhage  from  the  smaller  branches  in  the 
medulla  and  pons.  Bright's  disease  is  a  very  important  cause 
of  hemorrhage  into  the  medulla.  Caries  of  the  cervical  ver- 
tebrae, purulent  basilar  meningitis,  and  tumours  in  or  around 
the  medulla  predispose  to  haemorrhages  by  impairing  the  nutri- 
tion of  the  walls  of  the  vessels. 

Haemorrhage  is  also  produced  traumatically  through  injuries 
to  the  skull  and  back  of  the  neck.  Westphal  produced  capillary 
hasmorrhage  in  the  medulla  of  the  guinea-pig  by  light  blows  of  a 
hammer  on  the  head.  In  extensive  cerebral  haemorrhage,  which 
bre-aks  through  into  the  ventricles,  the  fourth  ventricle  often 
becomes  filled  with  blood  through  the  aqueduct  of  Sylvius. 

§  535.  Symptoms. — Very  little  is  known  of  the  symptoms  of 
active  hyperaemia  in  the  medulla,  but  it  is  probable  that  some 
of  the  symptoms  of  general  cerebral  hyperaemia  are  due  to 


328  VASCULAR  DISEASES   OF   THE 

congestion  of  the  medulla.  These  S3miptoms  are  dyspnoea,  slow- 
pulse,  vomiting,  general  convulsions,  and  certain  defects  of 
speech.  Certain  initial  symptoms  of  acute  bulbar  disease,  such 
as  pains  in  the  head  and  back  of  the  neck,  spasms  in  the  face 
and  tongue,  and  formication  in  the  region  supplied  by  the  fifth, 
are  probably  caused  by  congestion  of  the  medulla  oblongata. 

HcBiiwrrhage  into  the  medulla,  even  of  limited  extent,  is 
always  exceedingly  dangerous.  It  commences  generally  with 
the  most  alarming  symptoms,  and  not  unfrequently  causes 
instant  death.  In  these  cases  the  patients  fall  down  with 
a  cry  or  in  epileptiform  convulsions,  and  die  instantaneously. 
Large  effusions  of  blood  into  the  hemispheres  and  basal 
ganglia  sometimes  reach  the  fourth  ventricle  ;  they  irritate  and 
oppress  the  medulla,  quickly  producing  death,  preceded  by 
vomiting,  convulsions,  coma,  and  general  paralysis. 

Slight  hcemorrhage  into  the  medulla  generally  produces 
symptoms  of  an  alarming  and  very  threatening  nature,  and 
these  are  more  grave  the  nearer  the  effusion  is  to  the  respira- 
tory centre,  for  when  the  latter  is  affected  instant  death 
ensues.  In  cases  which  survive  a  longer  time  the  patients  utter 
a  loud  cry,  or  are  attacked  by  buzzing  in  the  ears,  dizziness, 
sudden  headache,  vomiting,  or  convulsive  spasm  of  the  body, 
followed  by  coma.  Epileptiform  convulsions  have  been  observed 
amongst  the  initial  symptoms  of  haemorrhage  into  the  medulla 
and  pons. 

The  motor  paralysis  varies  greatly  in  extent,  sometimes 
attacking  the  lower  extremities  only,  sometimes  only  the  upper, 
and  at  other  times  causing  hemiplegia.  In  most  cases  all  four 
extremities  are  either  completely  or  partially  paralysed.  Some 
of  the  bulbar  nerves  are  always  more  or  less  affected.  The 
hypoglossal,  facial,  spinal  accessory,  and  trigeminus  are  usually 
more  or  less  completely  paralysed,  and  sometimes  the  nerves  of 
the  orbit  also.  When  there  is  a  hemiplegia,  the  paralysis  of 
the  extremities  occupies  the  side  of  the  body  opposite  to  the 
extravasation,  while  paralysis  of  the  bulbar  nerves  occurs  on  the 
same  side,  giving  rise  to  a  characteristic  hemiplegia  alternans. 

Paralysis  of  sensation  when  present  follows  the  same  rule 
as  that  of  motion,  but  is  not  usually  so  well  developed. 
When  coma  is  present,  it  is  impossible  to  ascertain  anything 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  329 

with  respect  to  the  condition  of  sensation.  When  the  affection 
is  unilateral,  the  sensory  disturbances  are  also  crossed ;  but  owing 
to  the  peculiar  course  of  the  sensory  fibres  in  the  medulla,  we 
can  hardly  expect  a  sharply-defined  anaesthesia. 

Respiratory  disturbances  are  the  most  important  and 
characteristic  symptoms  of  the  affection.  If  fatal  asphyxia 
does  not  ensue  at  once,  the  respiration  is  impaired,  becoming 
irregular,  stertorous,  often  intermittent,  and  accompanied  with 
great  dyspnoea.  The  Cheyne-Stokes  respiration  is  frequently 
observed;  the  breathing  then  becomes  more  and  more  em- 
barrased  till  death  from  asphyxia  results.  Alterations  in  the 
action  of  the  heart  are  generally  less  prominent,  but  the  pulse 
is  usually  frequent,  irregular,  and  intermittent. 

Vaso-motor  changes  have  not  been  often  described,  but  in 
the  period  immediately  succeeding  the  haemorrhage,  unilateral 
or  bilateral  rise  of  temperature  of  the  skin  has  been  noticed. 
A  considerable  rise  of  temperature  occurs  during  the  death 
agony,  as  occurs  in  other  forms  of  apoplexy. 

Disturbances  of  speech  and  deglutition  and  unilateral  or 
bilateral  paralysis  of  the  soft  palate  result  from  the  parti- 
cipation of  the  bulbar  nerves  in  the  paralysis.  Deafness 
and  buzzing  of  the  ears  are  also  frequently  observed  from 
implication  of  the  auditory  nerves.  Frequently  recurring  vomit- 
ing and  a  continuous  troublesome  hiccough  have  been  observed 
as  symptoms.  Potain  found  polyuria  present  in  one  case. 
Mader  and  Desnos  found  albumen  in  the  urine  in  a  case  where 
the  kidneys  proved  to  be  normal  at  the  autopsy. 

In  cases  where  life  is  prolonged  the  electric  reactions  remain 
normal  in  the  extremities,  but  there  may  be  loss  of  faradic 
contractility  and  the  reaction  of  degeneration  in  the  muscles 
supplied  by  the  paralysed  cranial  motor  nerves. 

§  536.  Course. — The  disease  is  either  fatal  at  once  from 
paralysis  of  the  respiratory  centres,  or  death  does  not  result 
for  a  few  hours  or  days,  but  there  is  general  paralysis  and 
profound  unconsciousness ;  or  life  may  be  maintained  for  a 
considerable  time.  In  the  latter  case  the  patient  gradually 
recovers  his  consciousness,  some  of  the  paralytic  and  other 
symptoms  disappear,  and  nothing  remains  but  hemiplegia  or 


330  VASCULAR  DISEASES   OF  THE 

partial  paraplegia,  and  more  or  less  difficulty  in  articulation 
and  deglutition.  In  such  cases  contractures  are  very  liable  to 
ensue,  just  as  occurs  when  the  pyramidal  tract  is  interrupted  in 
any  other  part  of  its  course.  Very  little  is  known  of  the  symp- 
toms of  small  capillary  haemorrhages  in  the  medulla,  but  they 
are  probably  similar  to  those  produced  by  emboli  of  the  nutrient 
arteries  of  the  bulb, 

§  537.  Morbid  Anatomy. — Hypersemia  of  the  medulla  is 
characterised  by  the  same  anatomical  appearances  as  cerebral 
hypersemia,  and  requires  no  further  description.  A  similar 
remark  applies  to  haemorrhage  of  the  medulla.  A  clot  goes 
through  the  same  changes  in  the  medulla  as  in  the  brain, 
and  unless  it  is  rapidly  fatal  it  ends  in  the  formation  of  a 
contracted  scar  or  of  a  small  cyst.  Secondary  degenerations  of 
the  pyramidal  tracts  are  generally  developed.  Extravasations 
are  usually  of  small  size,  except  when  the  pons  is  simul- 
taneously affected,  and  then  they  may  be  large ;  they  are 
roundish,  resembling  an  olive  or  bean,  but  frequently  irregular. 
Near  the  median  line  we  meet  with  small  triangular  spots  of 
haemorrhage,  with  the  apex  pointing  forward,  corresponding  to 
the  territory  of  a  median  bulbar  artery. 

§  538.  Diagnosis. — It  is  probably  impossible  to  make  a 
special  diagnosis  of  hypersemia  of  the  medulla  oblongata.  Loss 
of  consciousness,  epileptiform  convulsions,  and  sudden  death 
are  sufficiently  characteristic  symptoms  of  severe  cases  of  he- 
morrhage into  the  substance  of  the  medulla.  In  cases  of  less 
severity  the  onset  may  be  attended  by  general  epileptiform  con- 
vulsions, vomiting,  hiccough,  more  or  less  threatening  respiratory 
disorders,  dysphagia,  disorders  of  speech,  paralysis  of  the  tongue 
and  soft  palate,  of  the  inferior  branches  of  the  facial  and  of 
the  abducens  oculi,  the  presence  of  albumen  and  sugar  in  the 
urine,  a  final  rise  of  temperature,  the  extension  of  paralysis 
to  all  four  extremities,  the  unequal  degree  of  paralysis  in  the 
extremities  of  one  side  and  the  face  and  tongue  on  the  other 
side,  and  the  abolition  of  all  reflexes  in  the  regions  supplied 
by  the  paralysed  bulbar  nerves.  It  may  be  concluded  that  the 
lesion  is  limited  to  the  anterior  half  of  the  floor  of  the  ventricle 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  831 

when  we  see  paralysis  of  the  abducens,  facial,  and  trigeminus, 
along  with  aural  disorders  and  sugar  and  albumen  in  the 
urine.  Haemorrhage  in  the  posterior  portion  of  the  rhomboid 
sinus  produces  paralysis  of  the  hypoglossus,  facial,  and  trige- 
minus, and  of  the  spinal  accessory  and  vagus,  accompanied  by 
grave  respiratory  disorders  and  usually  by  paralysed  extremities, 
and  it  is  a  symptom  of  some  importance  when  these  latter 
alternate  with  paralysis  of  the  tongue.  Alternate  paralysis  of 
an  upper  and  lower  extremity  probably  indicates  that  the  lesion 
is  situated  in  the  centre  of  the  decussation  of  the  pyramids. 

§  539.  Prognosis. — The  prognosis  is  very  unfavourable,  and 
when  the  haemorrhage  is  of  large  dimensions  the  lesion  is 
invariably  fatal.  There  is  only  hope  in  cases  of  very  limited 
haemorrhage,  or  when  the  localisation  is  very  favourable,  espe- 
cially when  it  is  far  removed  from  the  respiratory  centres.  The 
patient's  condition  may  then  improve  gradually  and  partial 
recovery  take  place. 

§  540.  Treatment — The  rules  of  treatment  are  the  same 
for  hyperaemia  and  haemorrhage  as  for  the  same  processes  in 
other  parts  of  the  brain.  Venesection,  combined  with  active 
stimulants,  is  the  most  suitable  treatment  in  severe  cases 
when  respiration  is  threatened;  the  latter  must  be  injected 
per  rectum,  as  the  patient  cannot  swallow. 

In  chronic  cases,  when  paralysis  continues  and  when  speech 
and  deglutition  are  impaired,  a  suitable  application  of  electricity 
is  indicated. 


332 


CHAPTER    VII. 


IV.— FUNCTIONAL  AND  SECONDARY  DISEASES  OF  THE 
SPINAL  CORD  AND  MEDULLA  OBLONGATA. 


(I.)  SPINAL  IRRITATION. 

§  541.  Definition. — This  disease  generally  occurs  in  the 
female  sex,  and  is  characterised  by  great  irritability  of  the 
sensory  functions,  along  with  motor  weakness. 

§  542.  Etiology. — The  female  sex  predisposes  to  the  disease, 
although  it  occasionally  occurs  in  men.  The  greater  number  of 
cases  are  met  with  between  the  fifteenth  and  thirtieth  years, 
and  more  frequently  in  neuropathic  constitutions. 

Everything  which  weakens  the  nervous  system  may  act  as 
an  exciting  cause,  as  emotional  disturbances,  excessive  bodily 
exertion,  severe  marches,  sexual  excesses,  bad  food,  exhausting 
diseases,  intoxication  with  alcohol  or  opium,  traumatic  agencies, 
and  exposure  to  cold. 

§  543.  Symptoms. — The  disease  generally  begins  with  ill- 
defined  pains  in  the  back,  especially  between  the  shoulder- 
blades,  the  patient  also  complains  of  excentric  pains,  increased 
nervous  irritability,  and  general  loss  of  power,  these  symptoms 
gradually  increasing  in  severity  until  the  disease  is  fully 
developed.  In  some  cases  the  development  occurs  quickly,  it 
may  be  in  a  few  days. 

When  the  affection  is  fully  developed  the  patient  complains 
of  a  general  feeling  of  illness,  and  displays  increased  mental 
irritability.  One  of  the  most  prominent  symptoms  is  pain  in 
the  back,  situated  in  various  spots,  most  frequently  between 


FUNCTIONAL   DISEASES   OF   THE   SPINAL   CORD.  333 

the  shoulder-blades,  in  the  back  of  the  neck,  and  less  frequently 
in  the  loins.  The  pain  is  aggravated  by  exertion,  and  the 
vertebral  column  is  exceedingly  sensitive  to  pressure,  the 
slightest  tap  over  some  of  the  spinous  processes  calling  forth 
expressions  of  pain.  Certain  spots  are  found  to  be  very  sensi- 
tive when  a  hot  spouge  or  the  cathode  of  a  galvanic  battery 
is  passed  along  the  spine.  The  patient  complains  of  neuralgi- 
form pains  in  various  parts  of  the  body.  These  pains  are  felt 
in  the  upper  extremities,  occiput  or  face,  lower  extremities, 
pelvic  region,  bladder,  genitals,  or  viscera.  Parsesthesise,  such 
as  tingling,  formication,  and  feelings  of  heat  or  of  cold,  are 
frequently  associated  with  the  neuralgiform  pains.  Actual 
anaesthesia  is  seldom  observed.  The  patient  feels  weary  and 
exhausted  on  slight  exertion,  and  walking  soon  becomes  im- 
possible owing  to  the  intolerable  pain  caused  by  it.  Most 
patients  soon  come  to  remain  on  their  backs,  and  even  move- 
ments of  the  upper  extremities  may  be  avoided  owing  to  the 
pain  occasioned.  Real  paralysis  does  not  exist,  although  in  a 
few  cases  a  certain  amount  of  paresis  may  be  present. 

Spasmodic  symptoms  in  the  form  of  fibrillary  twitchings, 
spasms  of  some  muscles,  choreic  movements,  and  hiccough 
are  observed.  Even  permanent  contractures  and  epileptic 
attacks  are  said  to  arise  from  spinal  irritation. 

Vaso-motor  disturbances  are  frequent.  Most  patients  suffer 
from  coldness  of  the  hands  and  feet,  which  are  often  cyanotic, 
and  the  patients  easily  turn  red  or  pale,  owing  to  undue  irrita- 
bility of  the  vaso-motor  nerves. 

Functional  disturbances  of  the  viscera  are  generally  present. 
The  most  common  symptoms  are  eructations,  nausea,  vomiting, 
palpitations,  asthmatic  breathing,  spasmodic  cough,  vesical 
spasms  with  increased  desire  to  urinate,  and  abundant  discharge 
of  pale  urine,  but  actual  paralysis  of  the  bladder  or  rectum 
does  not  occur.  Increased  mental  irritability  and  depression, 
along  with  sleeplessness,  are  almost  constant  symptoms.  There 
are  also  noises  in  the  ears,  dizziness,  and  inability  to  read  con- 
tinuously owing  to  the  occurrence  of  muscae  volitantes,  and 
other  disturbances  of  vision. 

§  544.   Varieties  of  Spinal  Irritation. — The  disease  may  be 


334  FUNCTIONAL  AND   SECONDARY  DISEASES   OF 

divided  into  three  classes,  according  as  the  symptoms  point  to 
the  upper,  middle,  or  lower  parts  of  the  cord. 

(1)  When  the  cervical  portion  is  affected,  the  pain  and  sensitiveness  are 
localised  in  the  cervical  vertebrae,  and  the  prominent  symptoms  are  then 
referred  to  the  head.  These  symptoms  are  giddiness,  sleeplessness,  dis- 
turbances of  the  special  senses,  pain  in  the  occiput,  and  pains  in  the  area 
of  distribution  of  the  nerves  of  the  brachial  plexus.  In  addition  to  these, 
nausea,  vomiting,  palpitation,  and  hiccough,  and  impairment  of  power 
in  the  upper  extremities  may  be  complained  of. 

(2)  If  the  dorsal  portion  of  the  cord  be  affected,  the  symptoms  are  local 
tenderness  of  the  dorsal  portion  of  the  vertebral  column,  intercostal  neu- 
ralgia, gastralgia,  nausea,  dyspepsia,  and  motor  and  sensory  disturb- 
ances in  the  lower  extremities. 

(3)  When  the  lumbar  portion  of  the  cord  is  affected,  the  symptoms  are 
neuralgia  in  the  lower  extremities  and  pelvic  organs,  spasm  or  paresis  of 
the  bladder,  cold  feet,  and  weakness  of  the  legs. 

§  545.  Course,  Duration,  and  Terminations. — The  course 
of  the  disease  is  usually  fluctuating,  and  relapses  occur  without 
apparent  cause.  Some  cases  run  a  comparatively  acute  course, 
but  the  duration  generally  extends  over  a  period  of  months  or 
years,  and  some  patients  suffer  from  occasional  attacks  all  their 
lives,  although  most  of  them  ultimately  recover. 

Nothing  is  known  with  regard  to  the  morbid  anatomy  of 
spinal  irritation.  It  is  probably  a  functional  disturbance  of  the 
cord,  accompanied  by  alternating  conditions  of  hyperemia  and 
anaemia. 

§  546.  Diagnosis. — Spinal  irritation  is  very  difficult  to  dis- 
tinguish from  hypersemia  of  the  cord.  In  severe  hypersemia 
distinct  paralysis  is  rarely  absent,  and  the  duration  of  the 
disease  is  not  as  long  as  that  of  spinal  irritation.  Hammond 
says  that  strychnine  injected  subcutaneously  does  good  in  spinal 
irritation,  and  harm  in  hypersemia.  Spinal  irritation  resembles 
in  some  respects  spinal  meningitis,  but  in  the  latter  there  are 
stiffness  and  painful  tension  of  the  muscles  of  the  back,  and 
fever. 

The  first  stage  of  meningeal  tumours  is  very  similar  to  spinal 
irrilfation,  but  in  the  former  only  deep  pressure  on  the  spinous 
processes  is  painful,  and  there  is  no  circumscribed  hyperaesthesia 
in  the  vertebral  region. 


THE  SPINAL   CORD  AND  MEDULLA  OBLONGATA.  835 

It  is  impossible  to  diagnosticate  spinal  irritation  from  hysteria 
in  many  cases,  and  indeed  the  two  affections  have  been  regarded 
as  identical. 

§  547.  Prognosis. — The  disease  is  always  chronic  and  may 
last  for  months  or  years,  but  the  prognosis  is  generally  favour- 
able, and  life  is  never  in  danger,  although  a  great  deal  of 
suffering  is  produced. 

§  548.  Treatment — The  treatment  of  spinal  irritation  offers 
difficulties  from  the  great  mental  irritability  and  changeable- 
ness  of  the  patient. 

The  first  endeavour  must  be  to  remove  the  cause  of  the 
diseases  when  this  is  possible.  The  next  endeavour  must  be 
to  improve  the  general  nutrition,  and  to  direct  special  treat- 
ment to  the  spinal  cord.  A  tonic  regimen  must  be  adopted, 
a  full  and  stimulating  diet,  as  well  as  moderately  free  use  of 
wine  or  even  in  some  cases  brandy  or  whisky.  Active  and 
passive  exercise  in  the  open  air  must  be  taken,  but  fatigue 
should  be  avoided,  and  the  patient  should  frequently  rest  in 
the  recumbent  posture.  The  air  of  mountains  and  forests  is 
useful,  as  well  as  a  moderate  hydropathic  treatment. 

The  most  useful  remedies  in  the  treatment  of  the  affection 
are  quinine,  iron,  zinc,  and  strychnine.  The  ascending  stabile 
constant  current  passed  through  the  vertebral  column,  including 
the  painful  portions  between  the  poles,  may  be  of  service.  Each 
sitting  should  be  short,  and  the  strength  of  the  current  moderate. 
The  negative  pole  acting  directly  on  the  painful  vertebra  has 
often  done  good.  Many  patients  of  this  class  are  benefited  by 
general  faradisation  and  central  galvanisation. 

Counter-irritants  applied  directly  over  the  painful  portion  of 
the  spine  often  effect  wonders.  Various  symptoms,  such  as 
neuralgiform  pains,  require  treatment  as  they  arise. 

(II.)   FUNCTIONAL  WEAKNESS   OF  THE  SPINAL  CORD. 

Neurasthenia  Spinalis. 

§  549.  Definition. — Neurasthenia  spinalis  is  observed  in  per- 
sons who  are  subject  to  the  general  symptoms  grouped  under 


336  FUNCTIONAL  AND  SECONDARY  DISEASES   OF 

the  popular  name  of  "  nervousness,"  but  in  it  the  functions  of 
the  cord  are  affected  in  a  special  degree. 

§  550,  Etiology. — The  affection  generally  occurs  in  neuro- 
pathic families,  and  the  male  is  more  liable  to  be  attacked  than 
the  female  sex.  Youth  and  middle  age  suffer  most  from  the 
disease,  and  it  is  more  common  in  the  upper  than  in  the  lower 
classes.  The  exciting  causes  are  excessive  mental  or  bodily 
exertion,  the  depressing  emotions,  and  sexual  excess. 

§  551.  Symptoms. — Patients  complain  chiefly  of  great  weak- 
ness of  the  lower  extremities,  accompanied  by  an  intense  feeling 
of  fatigue  on  slight  exertion.  A  dull  feeling  of  weariness  is, 
indeed,  often  felt  by  the  patient  in  the  lower  extremities  in  the 
morning  before  rising.  After  prolonged  exertion  this  feeling 
may  be  accompanied  by  occasional  tremors  of  the  legs,  and  a 
remarkable  stiffness  and  pain  of  the  muscles  of  the  lower  extre- 
mities, similar  to  that  produced  in  a  healthy  man  by  prolonged 
marching.  Symptoms  of  rapid  exhaustion  and  fatigue  may  be 
observed  in  the  arms  also,  but  never  reach  the  same  intensity 
as  in  the  legs. 

The  sensory  disturbances  consist  of  pain  in  the  back,  which  is 
aggravated  by  the  movements  of  the  muscles.  The  pain  is  not 
intense,  and  varies  greatly  in  its  time  of  occurrence  and  position. 
It  is  increased  or  brought  on  by  slight  exposure  to  cold,  and  by 
venereal  and  other  excesses. 

A  diffused  sensation  of  burning  in  the  skin  of  the  back  is 
often  observed,  especially  between  the  shoulder-blades,  which  is 
usually  accompanied  by  sensitiveness  of  some  of  the  spinous 
processes,  as  in  spinal  irritation.  Neuralgiform  pains  may  be 
present  in  the  extremities ;  they  are  never  of  long  duration, 
but  often  recur  after  unusual  exertion.  The  patient  also  com- 
plains of  numbness  and  formication,  especially  in  the  lower 
extremities,  of  cold  hands  and  feet,  and  occasionally  there  is  a 
burning  feeling  in  the  feet. 

The  sexual  functions  are  generally  more  or  less  interfered 
with,  there  is  diminished  power  of  erection  and  premature 
ejaculation,  and  the  act  of  coition  is  followed  by  remarkable 
prostration  and  restlessness  of  the  limbs. 


THE  SPINAL   CORD  AND   MEDULLA  OBLONGATA.  337 

There  may  be  a  little  dribbling  of  urine,  but  the  functions 
of  the  bladder  are  usually  normal.  The  patient  is  much 
troubled  with  sleeplessness,  and  feels  particularly  prostrate  in 
the  morning,  he  complains  of  a  sense  of  constriction  of  the  head, 
is  self-conscious  and  timid,  and  manifests  a  strong  tendency  to 
shed  tears.  Vertigo  is  usually  absent,  and  the  special  senses 
and  higher  mental  faculties  remain  unaffected. 

Dyspepsia,  along  with  constipation,  flatulence,  and  palpitation, 
is  frequently  present.  The  patients  are  generally  hypo- 
chondriacal, and  live  in  constant  dread  of  tabes  dorsalis,  or 
some  serious  affection  of  the  cord.  The  general  nutrition  is 
generally  impaired,  the  patient  loses  flesh,  acquires  a  sallow 
look,  and  becomes  ansemic.  There  is  always  great  sensitiveness 
to  cold  and  changes  of  weather. 

The  objective  symptoms  are  almost  entirely  negative.  The 
closest  examination  reveals  no  trace  of  motor  disturbances  or 
want  of  co-ordination.  The  sensory  disturbances  are  equally 
slight.  There  is  no  great  sensitiveness  of  the  spinous  processes, 
the  reflex  functions  of  the  skin  and  tendons  are  normal,  there  is 
no  muscular  atrophy,  and  no  change  in  the  electrical  reactions 
of  the  muscles. 

§  552.  Course,  Duration,  and  Termination. — The  disease 
may  occasionally  begin  rapidly,  but,  as  a  rule,  it  develops 
gradually  and  increases  in  severity  for  weeks  or  months,  and 
then  remains  more  or  less  stationary.  Slight  fluctuations  in  the 
intensity  of  the  symptoms  are  common.  Under  proper  treat- 
ment the  disease  begins  to  improve,  but  months  or  years  may 
pass  before  complete  recovery  occurs,  and  relapses  are  common. 
Intercurrent  febrile  affections  often  appear  to  influence  the 
affection  favourably.  In  some  cases  the  patient  is  compelled  to 
relinquish  business  on  account  of  the  affection. 

§  553.  Morbid  Physiology. — The  simultaneous  occurrence  of 
sensory  and  motor  disturbances  of  the  legs,  and  the  affections  of 
the  bladder  and  sexual  organs,  show  that  the  disease  is  of  spinal 
origin,  while  its  favourable  course,  and  the  absence  of  the  usual 
objective  symptoms  indicative  of  organic  disease  of  the  cord, 
show  that  it  is  a  functional  affection.  It  is  probable  th£»,t  a 
w 


338  FUNCTIONAL  AND  SECONDARY  DISEASES   OF 

certain  amount  of  anaemia  of  the  cord  exists  combined  with  an 
irritable  condition  of  the  nervous  tissue  itself,  leading  to  a  ready 
discharge  of  nervous  force  and  subsequent  exhaustion.  It  may 
also  be  assumed  that  repair  of  the  exhausted  tissues  does  not 
take  place  promptly  and  rapidly  as  in  health. 

§  554.  Diagnosis. — The  diagnosis  will  be  based  on  the  great 
disproportion  between  the  acute  subjective  complaints  of  the 
patient  and  the  almost  negative  result  of  objective  examination. 
The  diagnosis  becomes  clearer  when  in  addition  there  exists 
general  nervous  weakness  and  sleeplessness,  and  the  causes  are 
present  which  induce  the  disease. 

This  affection  might  be  mistaken  for  the  early  stage  of  tabes 
dorsalis,  but  in  the  latter  the  presence  of  the  lancinating  pains 
and  other  disturbances  of  sensibility,  the  girdle  sensation,  and 
especially  the  ataxic  symptoms  ought  to  render  the  diagnosis 
easy. 

Nervous  weakness  of  the  cord  may  be  distinguished  from 
active  hyperwrnia  by  the  absence  in  the  former  of  pain,  cuta- 
neous hypersesthesia,  and  symptoms  of  motor  irritation.  It  may 
be  distinguished  from  passive  hypersemia  by  the  absence  of 
paretic  symptoms  and  by  the  feeling  of  heaviness  in  the  legs. 

It  may  be  distinguished  from  incipient  myelitis  by  the 
absence  of  pargesthesise  and  aneesthesia,  of  paresis  or  paralysis  of 
the  limbs  and  of  pronounced  weakness  of  the  bladder. 

From  spinal  irritation  it  may  be  distinguished  by  the  fact 
that  in  the  former  the  sensory  disturbances,  as  dorsal  pains, 
neuralgias,  and  sensitiveness  of  the  spines  of  the  vertebrae,  are  the 
most  prominent  symptoms,  while  fatigue  on  exertion  and  sexual 
weakness  are  the  main  symptoms  of  the  latter, 

§  555.  Prognosis.— ^The  patient  generally  recovers  after  a 
time,  when  the  causes  of  the  affection  are  removed  and  a  suit- 
able treatment  adopted.  Relapses  are,  however,  of  frequent 
occurrence  when  the  patient  remains  exposed  to  the  exciting 
causes  of  the  disease. 

§  556.  Treatment. — Particular  attention  must  first  be  directed 
to  remove  the  exciting  causes  of  the  affection.     Great  attention 


THE   SPINAL   CORD  AND   MEDULLA   OBLONGATA.  839 

must  be  paid  to  the  regimen  and  diet  of  the  patient.  His 
work  should  be  light  and  agreeable,  and  he  should  retire  to 
rest  at  an  early  hour.  His  food  must  be  nourishing  and  easily- 
digestible.  Alcoholic  beverages  may  be  allowed  in  moderation, 
and  open-air  exercise,  short  of  fatigue,  should  be  enjoined. 
Sexual  excess  must  be  carefully  avoided,  although  coition  need 
not  be  entirely  forbidden. 

With  regard  to  the  special  treatment,  a  moderate  hydropathic 
treatment  has  been  found  useful.  Change  of  air  to  a  mountainous 
district  is  also  exceedingly  useful  in  promoting  recovery, 
Switzerland  and  the  Tyrol  being  very  suitable  places. 

An  ascending  stabile  galvanic  current,  of  moderate  intensity, 
should  be  applied  to  the  vertebral  column.  Iron,  quinine,  and 
strychnine  are  the  most  useful  internal  remedies.  Chalybeate 
baths  are  useful  for  anaemic  persons,  but  patients  who  are  sen- 
sitive to  cold  should  at  first  be  sent  to  the  thermal  brine  baths. 
Sea  baths  are  useful  in  the  after-treatment. 

Such  symptoms  as  sleeplessness,  pain,  spermatorrhoea,  im- 
potence, and  digestive  disorders  must  be  treated  in  the 
usual  way. 

(IIL)   EEFLEX  AND   SECOND AEY  PARAPLEGIA. 

§  557.  It  has  long  been  known  that  paralysis  of  the  lower 
extremities  is  frequently  associated  with  genito-urinary  diseases. 
These  affections  were  at  one  time  grouped  together  under  the 
name  of  urinary  paraplegice.  Brown-Sequard,  however,  showed 
that  essentially  the  same  symptoms  might  be  set  up  by  irrita- 
tive diseases  of  the  intestines,  and  other  organs,  and  on  the 
supposition  that  the  paralytic  phenomena  were  caused  by  a 
reflex  spasm  of  the  spinal  vessels  he  named  the  affection  reflex 
paraplegia.  The  paraplegia  which  is  associated  with  diseases 
of  the  urinary  organs  and  other  viscera  appears  to  consist  of 
several  varieties.  The  following  may  be  distinguished  :  (1) 
Secondary  myelitis,  caused  by  an  ascending  neuritis  of  the 
nerves  of  the  diseased  organ ;  (2)  Functional  paralysis,  caused 
by  some  mechanism  not  yet  accurately  determined,  but  which 
in  the  meantime  may  be  called  reflex  paraplegia;  and  (3) 
Paralysis,  caused  by  direct  propagation  of  inflammation  from 


340  FUNCTIONAL  AND   SECONDARY   DISEASES  OF 

the  nerves  of  the  urinary  passages  to  the  lumbar  and  sacral 
plexuses : — 

(1)  Secondary  Myelitis. — The  diseases  which  usually  cause  secondary 
myelitis  are  gonorrhcea,  stricture  of  the  urethra,  chrouic  cystitis,  prostatic 
abscess,  pyelo-nephritis  associated  with  calculus,  and  nephritis.  As  a  rule, 
spinal  paralysis  occurs  only  in  chronic  affections  of  the  urinary  passages. 

The  symptoms  are  usually  those  of  a  subacute  transverse  myelitis, 
situated  at  the  superior  part  of  the  lumbar  enlargement.  They 
are,  briefly,  formication  and  numbness  in  the  lower  extremities,  girdle 
sensation,  and  later  anaesthesia  or  analgesia.  Paraplegia  is  soon  established, 
with  excess  of  the  reflex  actions,  but  these  become  diminished  and  ulti- 
mately lost  as  the  lumbar  enlargement  is  involved,  cystitis  and  bed-sores 
then  form,  and  soon  cause  death.  Inflammatory  action  may  at  times  ex- 
tend upwards  and  involve  the  upper  extremities  in  the  paralysis.  It  has 
been  proved  experimentally  that  inflammation  of  the  sciatic  nerve  may 
cause  myelitis  (Tiesler),  and  several  cases  are  recorded  in  which  injury 
of  it  has  been  followed  by  myelitis  in  man.  A  case  is  recorded  by 
Cornil  in  which  tumour  of  the  cauda  equina  produced  a  myelitis  of  the 
central  grey  substance  of  the  cord,  along  with  sclerosis  of  the  posterior 
columns,  and  similar  cases  have  been  recorded  by  Simon,  Lange,  and 
Leyden  ;  a  case  of  the  kind  has  come  under  my  own  observation. 
In  the  case  already  mentioned,  under  the  care  of  Dr.  Morgan, 
a  severe  injury  to  the  sciatic  nerve  was  followed  by  the  symptoms  of 
subacute  central  myelitis.  After  death  a  microscopical  examination 
showed  perineuritis  of  the  injured  sciatic  nerve,  central  myelitis,  reaching 
up  the  whole  length  of  the  cord,  along  with  grey  degeneration  of  the 
posterior  columns  in  the  lumbar  and  dorsal  regions,  but  limited 
to  the  columns  of  GoU  in  the  cervical  region,  the  portion  which  adjoins 
the  posterior  commissure  being  healthy  too  in  the  lumbar  region. 

In  a  case  related  by  Dumenil,  a  neuritis  of  the  sciatic  nerve  was 
followed  by  paraplegia,  and  at  a  later  period  by  paralysis  of  one  of 
the  upper  extremities.  The  paralysed  muscles  became  atrophied  with 
diminution  of  their  faradic  contractility.  At  the  autopsy  the  grey 
matter  was  found  diseased,  while  the  white  substance  was  unaffected. 
Charcot  describes  a  case  in  which  lesion  of  one  of  the  nerves  of  the 
forearm  was  first  followed  by  inflammation  of  the  peripheral  portion  of 
the  nerve,  atrophy  of  the  muscles  of  the  hand,  and  pemphigoid  eruptions, 
while  at  a  later  period  the  arm  of  the  opposite  side  was  affected  with 
atrophy  and  ansesthesia. 

(2)  Reflex  Paraplegia. — In  this  form  of  the  disease  the  paralysis  never 
extends  to  the  upper  extremities,  while  the  lower  extremities  are  only 
paretic,  and  never  completely  paralysed.  There  is  also  complete  absence 
of  pains  in  the  loins,  girdle  pains,  dyssesthesise,  ancesthesia,  muscular 
tension,  and  contractures,  paralysis  of  the  bladder,  bed-sores,  and 
other  trophic  disturbances.      The  paralytic  symptoms  are  variable  in 


THE   SPINAL  CORD  AND   MEDULLA  OBLONGATA.  341 

their  intensity,  and  may  improve  rapidly  if  there  be  an  amendment  of 
the  peripheral  lesion  which  is  the  cause  of  the  affection. 

Browu-Suquard  observed  that  ligature  of  the  hilus  of  the  kidney  in 
animals  produced  spasm  of  the  vessels  of  the  spinal  cord,  and  he  argued 
that  the  paralysis  which  is  caused  by  diseases  of  the  urinary  organs  is 
occasioned  by  ansemia  of  the  spinal  cord.  Charcot,  on  the  other  hand, 
believes  that  the  peripheral  irritation  produces  an  inhibitory  effect  on  the 
spinal  cord.  In  chronic  Bright's  disease  the  fibroid  changes,  which  the 
spinal,  like  the  other  vessels  of  the  body  undergo,  must  cause  anaemia 
of  the  cord,  which  may,  in  exceptional  cases,  reach  such  a  degree  as  to 
cause  some  amount  of  paralysis. 

(3)  Peripheral  paralysis  from  extension  of  neuritis  from  the  nerves  of 
the  urinary  organs  is  rare.  Kussmaul  reports  a  case  in  which  inflamma- 
tion of  the  urinary  passages  had  given  rise  to  a  neuritis,  which  extended 
to  the  nerves  of  the  sacral  and  lumbar  plexuses.  During  life,  the  patient 
complained  of  shooting  pains  along  the  course  of  the  sciatic  nerves,  while 
there  was  paresis  of  the  lower  extremities.  Pelvic  abscesses  may  cause 
inflammation  of  the  sacral  plexus,  and  thus  occasion  paralysis  and  anaes- 
thesia of  one  or  both  the  lower  extremities  (Adams). 

(IV.)    SALTATORY   SPASM. 

§  558.  Bamberger  first  described  in  1859,  under  the  name  of 
saltatory  spasm,  two  cases  in  which,  as  soon  as  the  patients 
set  their  feet  on  the  floor,  the  lower  extremities  became  the 
subject  of  such  strong  clonic  convulsions  that  the  patients 
were  thrown  repeatedly  into  the  air.  Similar  cases  have  been 
reported  by  P.  Guttmann,  and  A.  Frey  has  recently  communi- 
cated a  case  and  examined  the  subject  in  detail. 

The  common  characteristic  of  all  the  published  cases  of 
the  affection  is  that  there  is  a  great  increase  of  reflex 
excitability  in  certain  nerve  tracts,  so  that  on  the  sole  of  the 
foot  being  placed  on  the  floor  a  singular  spasm  occurs,  which 
has  the  effect  of  throwing  the  patient  repeatedly  into  the  air. 
These  spasmodic  contractions  continue  as  long  as  the  patient 
maintains  the  erect  posture,  and  they  cause  the  patient  to  hop 
and  jump  on  the  floor,  and  render  him  quite  unable  to  stand 
still  for  an  instant.  When  the  patient  sits  or  lies  down  the 
movements  disappear,  but  can  be  instantly  made  to  reappear 
by  tickling,  or  pressing  on  the  soles  of  the  feet. 

In  saltatory  spasm  the  reflex  mechanism  of  the  cord  is 
alone    affected,  and  there   is    complete   absence   of  paralysis. 


342  FUNCTIONAL  AND   SECONDARY  DISEASES   OF 

In  some  of  the  reported  cases  other  spasmodic  manifestations 
are  mentioned,  but  the  spasm  which  causes  the  patient  to  hop 
on  assuming  the  erect  posture  is  by  far  the  most  characteristic 
feature  of  the  disease. 

It  was  demonstrated  in  Frey's  case  that  the  reflex  action 
did  not  begin  in  the  skin,  and  he  regards  the  symptom  as 
being  due  to  tension  and  stretching  of  the  muscles,  and  it  is  not 
by  any  means  improbable  that  the  spasms  are  really  due 
to  increase  of  the  reflex  excitability  of  the  tendons.  Bam- 
berger's first  case  appears  to  show  that  the  reflex  action  may 
originate  in  the  skin.  His  second  case  was  associated  with 
hysteria,  and  therefore  allied  to  so-called  chorea  major.  In 
Frey's  case  paresis,  contractures,  and  atrophy  were  present,  and 
consequently  the  saltatory  spasm  was  to  be  regarded  as  a 
symptom  of  chronic  myelitis.  The  distribution  of  the  spasms 
varies  greatly  in  individual  cases.  They  are  at  times  limited 
to  the  legs,  while  at  other  times  they  extend  to  the  muscles  of 
the  back,  face,  neck,  and  pupils,  but  the  arms  always  remain  un- 
affected. Mental  influences  have  been  found  to  aggravate  the 
spasm  in  some  cases,  and  to  arrest  it  in  others.  The  diagnosis 
of  the  affection  is  easy  on  account  of  the  very  characteristic 
hopping  movements  as  soon  as  the  feet  touch  the  floor. 

§  559.  T7^eatment. — In  Bamberger's  first  case  the  admini- 
stration of  morphia  appeared  to  have  a  beneficial  effect,  but  it 
is  doubtful  how  far  treatment  has  been  attended  by  good  results. 
The  agents  most  worthy  of  trial  are  bromide  of  potassium. 
Calabar  bean,  ergotine,  conia,  and  atropia. 

(V.)  TONIC  SPASMS  IN  MUSCLES  CAPABLE  OF  VOLUNTARY 
MOVEMENT. 

§  560.  In  this  affection,  if  it  can  be  called  a  separate  affec- 
tion, the  voluntary  muscles  become  the  subjects  of  increased 
tension  and  tonic  spasms  the  moment  any  attempt  is  made  to 
move  them.  Such  cases  manifest  a  marked  hereditary  ten- 
dency. The  most  remarkable  cases  of  this  kind  are  recorded 
by  Dr.  Thomsen,  who  had  himself  been  subject  to  the  disease 
since  childhood.  The  disease  appeared  in  his  children,  brothers 
and  sisters,  and  could  be  traced  through  four  generations  of  his 


THE   SPINAL   CORD  AND  MEDULLA  OBLONGATA.  343 

ancestors.     The  disease  begins  in  early  life,  and  Dr.  Thomsea 
was  able  to  recognise  it  in  his  children  even  in  the  cradle. 

The  disturbance  of  movement  consists  in  a  peculiar  stiffness 
and  rigidity  of  the  muscles  on  voluntary  movement,  and  this  may 
increase  to  a  regular  tonic  cramp,  so  that  intended  movements  are 
entirely  prevented  and  the  patients  fall  to  the  ground.  Volun- 
tary contraction  of  the  muscles  occurs  very  slowly ;  but  when 
once  it  has  begun  it  persists  long  and  terminates  only  very 
gradually,  so  that  patients  cannot  at  once  let  go  articles  they 
have  firmly  seized.  When,  however,  after  a  powerful  voluntary 
exertion  the  muscles  are  got  to  act,  the  movements  are  effected 
with  increasing  freedom  and  ease,  so  as  to  be  little  distinguished 
from  healthy  movements.  Emotional  disturbances,  increased 
attention  directed  to  the  movements,  and  cold,  all  act  unfavour- 
ably on  the  condition.  The  muscular  system  in  these  patients 
is  well  developed  ;  they  are  capable  of  performing  a  large 
amount  of  labour,  and  their  general  health  and  mental  func- 
tions are  unaffected. 

§  561.  Morbid  Physiology. — Thomson  thought  that  the 
affection  was  mainly  of  psychical  origin,  but  there  is  not  suffi- 
cient evidence  in  support  of  this  opinion.  The  view  ultimately 
adopted  by  Seeligmuller,  that  it  arises  from  a  congenital  or 
inherited  affection  of  the  pyramidal  tracts  of  the  cord,  appears 
more  likely  to  prove  correct.  The  question,  however,  can  only 
be  decided  by  further  observations. 

§  562.  Treatment — No  treatment  has  hitherto  been  of  any 
service. 

(VI.)  INTERMITTENT   SPINAL  PARALYSIS. 

§  563.  One  of  the  most  remarkable  of  the  manifestations  of 
malarial  infection  is  the  occurrence  of  intermittent  attacks  of 
paraplegia. 

In  the  recorded  cases  (Hertz,  Romberg,  Hartwig)  paraplegia 
became  rapidly  developed  and  advanced  steadily  to  complete 
motor  paralysis.  The  paralysis  of  the  lower  extremities  may 
or  may  not  be  accompanied  by  anaesthesia  and  paralysis  of  the 


344  FUNCTIONAL  AND   SECONDARY   DISEASES   OF 

sphincters.  The  paraplegia  usually  disappears  in  the  course  of 
a  few  hours,  and  gives  place  to  an  almost  complete  intermission, 
accompanied  by  the  appearance  of  a  critical  sweat.  This  pro- 
cess is  repeated,  in  a  more  or  less  regular  manner,  in  the 
quotidian,  tertian,  or  quartan  type,  and  the  affection  is  either 
cured  or  favourably  influenced  by  quinine. 

§  564.  Morbid  Physiology. — All  we  know  about  the  patho- 
logy of  this  affection  is  that  it  is  in  all  probability  due  to  the 
malarial  poison  acting  on  the  spinal  cord,  but  of  its  mode  of 
action  we  know  nothing. 

§  565.  Diagnosis. — The  intermittent  character  of  the  affec- 
tion renders  the  diagnosis  easy,  and  the  treatment  is  the  same 
as  that  which  is  applicable  to  all  forms  of  intermittent  fever. 

{VII.)   TOXIC  SPINAL  PARALYSIS. 

§  566.  Opium,  belladonna,  arsenic,  phosphorus,  lead,  mercury, 
carbonic  oxide,  sulphide  of  carbon,  tobacco,  camphor,  ergot, 
alcohol,  absinthe,  mushrooms,  copaiba,  and  many  other  toxic 
agents  induce  various  forms  of  motor  paralysis,  such  as  para- 
plegia, paralysis  of  groups  of  muscles,  or  of  single  extremities, 
and  general  paralysis. 

Permanent  paralysis  is  only  caused  as  a  rule  by  these  agents 
when  the  organism  is  exposed  for  a  long  period  to  their 
influence,  although  occasionally  paralysis  may  result  from  a 
temporary  poisoning. 

Absolutely  nothing  is  known  with  regard  to  the  nature  and 
locality  of  the  lesion  caused  by  the  majority  of  these  agents. 
Landouzy  has  recently  collected  all  the  various  forms  of  para- 
lysis which  occur  in  the  course  of  or  subsequent  to  infective  and 
other  acute  diseases,  but  inasmuch  as  many  of  these  are  not  of 
spinal  origin,  it  will  be  well  to  defer  their  consideration  at 
present.  This  subject  will  be  subsequently  treated  in  greater 
detail. 

{VIII. )  HYSTERICAL  PARAPLEGIA. 

This  form  of  paralysis  will  be  described  at  greater  length 
hereafter,  and  is  mentioned  in  this  place  only  with  the  view 


THE   SPINAL   CORD   AND   MEDULLA   OBLONGATA.  345 

of  reminding  the  reader  to  be  carefully  on  his  guard  lest  hys- 
terical paralysis  be  mistaken  for  more  serious  disease.  In 
hysterical  paraplegia,  the  lower  extremities  are  generally  main- 
tained in  a  condition  of  rigid  extension,  while  the  feet  are  in 
the  position  of  extreme  talipes  equino-varus.  As  a  rule,  how- 
ever, there  is  no  muscular  atrophy,  the  electric  reactions  are 
normal,  and  the  limbs  become  quite  relaxed  when  chloroform  is 
administered. 


346 


CHAPTER   VIII. 


v.— TRAUMATIC  DISEASES,  TUMOURS,  AND  ABNOR- 
MALITIES OF  THE  SPINAL  CORD  AND  MEDULLA 
OBLONGATA. 


(I.)   WOUNDS    OF    THE    SPINAL    CORD    AND    MEDULLA 
OBLONGATA. 

The  affections  comprised  in  this  section  are  acute  traumatic 
lesion  of  the  substance  of  the  cord  and  medulla  oblongata. 

§  567.  Etiology. — In  fractures  and  luxations  of  the  spinal 
column  the  injured  vertebrae  may  be  so  displaced  as  to  cause 
compression  and  crushing  of  the  cord. 

Gunshot  wounds  often  injure  the  spinal  cord  either  by  the 
entrance  of  the  bullet  into  the  spinal  canal  or  by  fracture  of  the 
vertebrae.  Stabs  and  cuts  of  the  spinal  cord  are  rare  ;  but  sharp 
instruments  have  been  known  to  enter  the  cord,  the  point  of  the 
instrument  having  entered  the  canal  either  by  dividing  the 
vertebral  arches  or  by  passing  through  the  intervertebral 
spaces. 

Injuries  of  the  medulla  oblongata  may  be  produced  by  a 
sharp  instrument  piercing  between  the  occiput  and  altas,  by 
bullets,  splinters  of  bone,  blows  on  the  back  of  the  neck  without 
fracture,  and  on  the  top  of  the  head  by  contre  coup.  Fractures 
and  dislocations  of  the  first  two  cervical  vertebrae  are  also 
important  causes  of  wounds  of  the  medulla  oblongata.  Dis- 
location of  the  first  vertebra,  or  rupture  of  the  odontoid 
ligament,  is  accompanied  by  a  backward  displacement  of  the 
odontoid  process,  which  presses  against  the  anterior  surface  of 
the  medulla,  and  causes  instant  death. 


TRA.UMATIC    DISEASES   OF   THE   SPINAL   CORD.  347 

§  568.  Symptoo7is. 
1.  Wounds  of  the  Spinal  Coed. 

The  symptoms  may  be  subdivided  into  those  which  are 
caused  by  (a)  comparatively  slight  injuries  of  the  cord,  such  as 
simple  incised  and  punctured  wounds ;  and  (6)  those  which 
arise  from  the  more  serious  lesions,  such  as  compression,  crush- 
ing, and  tearing  of  the  cord. 

(a)  The  symptoms  which  indicate  that  an  injury  by  cutting  or 
stabbing  in  the  neighbourhood  of  the  spine  has  penetrated  the 
cord  will  at  first  be  those  caused  by  loss  of  conduction  to  and 
from  the  brain  in  the  portions  situated  below  the  seat  of  the 
injury.  At  the  moment  the  injury  is  received  there  is  usually 
motor  paralysis  of  various  extent  in  the  form  of  paraplegia, 
hemi-paraplegia,  or  general  paralysis.  If  the  cord  be  com- 
pletely divided,  there  is  complete  anaesthesia  of  the  paralysed 
parts;  but  if  only  one-half  of  the  cord  be  divided,  the  sensory 
paralysis  is  situated  on  the  side  opposite  to  the  injury  and  to 
the  motor  paralysis.  The  anaesthesia  is  sometimes  partial,  and 
if  the  lesion  be  very  restricted,  hypersesthesia  in  the  form  of  a 
girdle  is  present.  If  the  injury  be  of  any  considerable  extent, 
paralysis  of  the  bladder  and  rectum  occurs,  and  there  is  also 
vaso-motor  paralysis  with  increased  temperature  and  redness  of 
the  regions  affected  by  the  motor  paralysis.  The  reflex  actions 
are  usually  abolished  at  first  owing  to  the  shock ;  but  if  the 
lesion  be  situated  in  the  dorsal  or  cervical  regions,  they  may 
after  a  time  be  exaggerated. 

Girdle  pains,  caused  by  irritation  of  the  posterior  roots  at  the 
seat  of  injury,  are  usually  present.  After  a  time  the  symptoms 
of  secondary  traumatic  myelitis  complicate  those  caused  by  the 
primary  lesion.  The  symptoms  of  irritation  now  appear,  such 
as  girdle  pains,  active  pains  in  the  paralysed  parts,  cutaneous 
hyperaBsthesia  of  variable  extent,  and  twitchings  and  spasms  of 
single  muscles  and  groups  of  muscles. 

When  the  inflammatory  action  spreads  through  the  whole 
thickness  of  the  cord,  the  paralysis  extends  in  the  transverse 
direction,  so  that  even  when  the  wound  has  only  injured  a  small 
portion  of  the  transverse  diameter  of  the  cord,  complete  para- 
plegia, para-anaesthesia,  and  paralysis  of  the  vaso-motor  paths, 


348  TRAUMATIC   DISEASES   AND   ABNORMALITIES   OF 

bladder,  and  rectum  may  occur.  When  the  lesion  is  situated 
high  up,  disturbances  of  respiration  become  prominent,  and 
various  oculo-pupillary  phenomena  and  vaso-motor  disturbances 
of  the  head  and  face  may  be  present.  At  a  later  period  bed- 
sores, cystitis,  pygemia,  and  septicaemia  supervene  with  all  their 
deleterious  consequences. 

(6)  The  symptoms  which  indicate  that  the  cord  is  crushed 
or  torn  in  severe  injuries  of  the  spine  are  complete  paralysis 
and  anaesthesia  of  the  portion  of  the  body  below  the  seat  of 
injury.  The  reflex  actions  are  abolished,  there  are  retention  of 
urine,  involuntary  evacuations  with  constipation  and  meteorism, 
painful  erections,  and  elevation  of  the  temperature  of  the  body 
below  the  lesion.  The  local  symptoms  of  injury  to  the  spine 
and  of  displacement  of  the  vertebrae  are  of  course  present. 
The  symptoms  of  acute  traumatic  myelitis  appear  in  a  few 
days,  consisting  of  bed-sores  and  pyaemia,  with  their  usual  con- 
sequences. 

If  the  lumbar  region  be  crushed,  there  is  rapid  atrophy  of  the 
muscles  of  the  legs,  with  loss  of  electrical  contractility,  and 
cystitis.  When  the  cervical  region  is  injured,  the  temperature 
may  rise  to  an  excessive  height  (43°— 44°  C.)  (109°— 111°  F.). 
In  some  cases,  when  the  dorsal  region  has  been  injured,  the 
temperature  has  been  abnormally  low  for  some  days  before 
death  (Nieder).  The  severer  cases  are  rapidly  fatal  by  paralysis 
of  respiration,  while  death  is  caused  in  other  cases  by  acute 
bed-sores  and  pyaemia.  In  partial  crushing  of  the  cord  the 
symptoms  run  a  milder  course. 

§  569.  Varieties. — The  symptoms  vary  according  to  the  level 
at  which  the  lesion  is  seated. 

If  the  cord  be  injured  at  the  level  of  the  first  or  second  cervical 
vertebra,  death  usually  occurs  at  once ;  and  when  the  lesion  is  situated 
above  the  origin  of  the  phrenic  nerves,  respiration  is  only  maintained 
by  the  forced  action  of  the  auxiliary  muscles  of  inspiration,  and  the  case 
terminates  fatally  in  a  brief  space  of  time. 

If  the  lesion  be  situated  in  the  cervical  region  below  the  origin  of  the 
phrenic  nerves,  the  arms  are  partially  and  the  legs  completely  paralysed, 
anaesthesia  being  also  partial  in  the  former  and  complete  in  the  latter; 
inspiration  is  performed  by  the  diaphragm,  expiratory  acts  are  feeble, 
painful  erections  are  often  present,  and  life  may  be  prolonged  for  some 
time. 


THE   SPINAL   CORD   AND  MEDULLA  OBLONGATA.  349 

If  the  lesion  be  situated  in  the  dorsal  region,  the  arms  remain  un- 
affected, the  muscles  of  the  trunk  and  lower  extremities  are  paralysed 
below  the  seat  of  the  lesion,  the  reflex  actions  soon  become  exaggerated, 
painful  erections  are  rare,  the  bladder  and  rectum  may  after  a  time  become 
paralysed,  and  bed-sores  supervene  with  their  usual  consequences,  or  the 
myelitis  assumes  an  ascending  course,  and  the  patient  dies  from  asphyxia. 

If  the  lesion  be  situated  in  the  lumbar  region,  the  arms  and  the  greater 
portion  of  the  trunk  are  unaffected,  the  legs,  bladder,  and  rectum  are  totally 
paralysed,  reflex  actions  of  all  kinds  are  abolished,  there  are  no  erections, 
and  the  muscles  of  the  lower  extremities  undergo  rapid  atrophy,  with  ex- 
tinction of  their  electrical  reaction.  The  symptoms  arising  from  lesion  of 
the  Cauda  equina  are  somewhat  similar,  but  in  it  the  region  supplied  by 
the  lumbar  plexus  is  unaffected. 

2.  Wounds  op  the  Medulla  Oblonuata. 

§  570.  If  the  injury  to  the  medulla  be  a  severe  acute  one, 
the  patient  collapses  as  if  struck  by  lightning,  and  dies  instan- 
taneously. Sometimes  he  gives  utterance  to  a  piercing  cry 
before  falling,  or  death  may  be  accompanied  by  a  few  transitory 
convulsions.  All  this  results  from  sudden  paralysis  of  the 
respiratory  centre  and  complete  interruption  of  all  the  con- 
ducting paths  between  the  spinal  cord  and  the  brain. 

When  the  wound  is  less  severe,  or  when  the  medulla  is  only 
partially  lacerated,  the  affection  may  last  for  some  time,  but  these 
cases  too,  as  a  rule,  terminate  suddenly.  It  is  probable  that 
patients  sometimes  survive  very  small  injuries  to  the  medulla, 
but  this  is  difficult  to  prove.  Sudden  death  may  perhaps  some- 
times occur  from  simple  concussion  of  the  medulla  in  the  entire 
absence  of  any  serious  lesion. 

§  571.  Morbid  Anatomy. 

Simple  incised  or  punctured  wounds  produce  injuries  of 
various  size  and  depth.  The  edges  of  the  wound  project  at 
first  beyond  the  pia  and  the  wound  is  closed  with  coagulated 
blood.  In  a  few  days  the  edges  are  still  further  protruded, 
while  the  neighbouring  parts  of  the  cord  are  more  or  less 
softened,  and  the  membranes  are  reddened  and  inflamed  and 
covered  with  fibro-purulent  exudations.  In  animals  at  least, 
and  probably  also  in  man,  if  life  be  preserved,  the  edges  of  the 
wound  heal,  and  a  cicatrix  of  connective  tissue  is  formed. 

Crushing  produces  softening  and  disintegration  of  the  cord, 


850  TRAUMATIC  DISEASES   AND   ABNORMALITIES   OF 

along  with  congestion  and  haemorrhage  into  the  membranes. 
The  crushed  spot  is  usually  flat  and  thin,  and  the  medullary 
substance  is  changed  into  a  dark  red  or  chocolate  coloured  mass 
composed  of  blood  and  the  ddbris  of  nerve -substance.  The 
adjoining  parts  become  congested  and  subsequently  undergo 
inflammatory  softening.  The  microscope  shows  granular  cor- 
puscles, detritus  of  myeline,  decomposed  blood  corpuscles, 
pigment  and  blood  crystals,  and  remnants  of  ganglion  cells, 
along  with  inflammatory  swelling  and  disintegration  of  nerve 
fibres  and  axis  cylinders.  In  a  few  weeks  the  cord  for  a  con- 
siderable distance,  both  above  and  below  the  injury,  undergoes 
softening,  and  this  is  specially  apt  to  occur  in  the  lower  part  of 
the  cord.  Ascending  and  descending  secondary  degeneration 
occur  when  life  is  prolonged,  and  in  several  cases  fatal  within 
a  few  days  from  the  date  of  injury  I  have  found  decided  evi- 
dences of  a  central  myelitis  up  to  the  medulla  oblongata. 

If  the  patient  live,  the  destroyed  nerve  tissue  becomes 
absorbed,  and  a  kind  of  cicatrix  is  formed,  which  may  enclose 
cystic  cavities  containing  clear  fluid.  Regeneration  of  nerve 
substance  is  not  known  to  occur  in  man. 

Complete  severance  of  the  cord  occasionally  occurs,  and  then 
the  pia  is  also  torn,  and  the  two  ends  of  the  cord  are  separated 
by  a  considerable  space.  The  spinal  dura  mater  may  remain 
uninjured.  Inflammatory  softening  occurs  as  after  crushing, 
and  extends  more  or  less  upwards  and  downwards. 

The  anatomical  changes  found  in  the  medulla  when  it  is 
wounded,  lacerated,  or  crushed  resemble  the  acute  injuries  of 
the  spinal  cord. 

§  572.  Course,  Duration,  and  Termination. — In  simple 
incised  wounds  of  the  cord  a  comparative  cure  may  be  effected, 
and  life  retained  for  many  years.  Physiological  experiment 
shows  that  animals  may  be  kept  alive  for  a  long  period  even 
after  complete  division  of  the  cord,  and  it  is  quite  possible  that 
lesions  of  moderate  severity  may  undergo  repair.  As  a  rule, 
however,  the  secondary  myelitis  set  up  continues  to  increase, 
the  paralysis  becomes  more  complete,  bed-sores  with  all  their 
attendant  evils  make  their  appearance,  and  the  patient  dies 
after  protracted  suffering.      The  severe  forms  of  injury  to  the 


THE    SPINAL   CORD  AND   MEDULLA   OBLONGATA.  351 

spinal  cord  are  always  fatal.  Death  may  take  place  a  few  hours 
or  days  after  the  injury  from  shock  or  paralysis  of  respiration, 
but  in  some  cases  life  may  be  protracted  for  many  months. 

Acute  severe  injury  to  the  medulla  oblongata  causes  instant 
death,  and  slight  injuries  are  exceedingly  dangerous,  because 
the  inflammatory  action  set  up  by  them  generally  leads  rapidly 
to  a  fatal  termination. 

§  573.  Diagnosis. — In  the  case  of  a  wound  of  the  pia  mater 
the  occurrence  of  meningeal  hgemorrhage  might  give  rise  to  the 
idea  of  injury  of  the  cord.  In  meningeal  haemorrhage,  however, 
the  symptoms  of  irritation  are  very  prominent  at  the  outset, 
while  those  of  paralysis  are  less  severe  than  in  injury  of  the 
cord. 

Hcematomyelia  induces  a  certain  amount  of  crushing  of  the 
cord,  and  gives  rise  to  similar  symptoms,  but  in  it  there  is 
usually  no  history  of  external  injury,  and  when  there  is,  the 
diagnosis  between  the  two  affections  is  not  of  much  consequence. 

Cases  of  severe  concussion  of  the  cord  may  usually  be 
recognised  by  the  absence  of  a  clear  demarcation  of  the 
anaesthesia  and  paralysis,  and  by  the  absence  of  bed-sores,  and 
other  trophic  changes.  If  dislocations  of  the  vertebrse  are  found 
to  exist,  crushing  of  the  cord  is  more  probable. 

§  574.  Prognosis. — In  all  the  severer  forms  of  injury  the 
prognosis  is  exceedingly  unfavourable,  but  in  cases  of  partial 
injury  and  simple  incised  wounds  a  certain  amount  of  recovery 
may  take  place.  Sudden  injury  to  the  medulla  oblongata  is 
almost  uniformly  fatal. 

§  575.  Treatment. — The  associated  traumatic  myelitis  must 
be  treated  according  to  the  principles  applicable  to  other  forms 
of  acute  inflammation  of  the  cord. 


(IL)  SLOW  COMPRESSION  OF   THE   SPINAL   CORD    AND 
MEDULLA  OBLONGATA. 

§  576.  In  all  the  lesions  comprised  under  this  section  an 
external   force   slowly  and   gradually  compresses  the  cord  or 


352  TRAUMATIC   DISEASES  AND   ABNORMALITIES  OF 

medulla  oblongata  in  a  limited  longitudinal  extent,  giving  rise 
to  characteristic  groups  of  symptoms. 

§  577.  Etiology. — Any  circumstance  which  gradually  narrows 
the  spinal  canal  and  leads  to  a  slowly  increasing  compression 
of  the  cord  may  become  a  cause  of  myelitis  by  compression. 
Such  compression  may  be  caused  by  meningeal,  perimeningeal, 
and  intramedullary  tumours,  inflammatory  and  hsemorrhagic 
processes,  and  parasites.  Diseases  of  the  vertebral  column, 
especially  caries  of  the  vertebrge,  constitute  the  most  important 
causes  of  compression  of  the  cord,  and  may  produce  pressure  on 
the  cord  in  several  ways.  The  wasting  and  sinking  of  the  bodies 
of  the  vertebrae  produce  kyphosis,  which  may  narrow  the  ver- 
tebral canal  to  such  an  extent  as  to  compress  the  cord. 

In  caries  of  the  vertebrae,  however,  compression  of  the  cord  is 
generally  produced  by  the  extension  of  the  inflammatory  process 
in  the  bone  to  the  spinal  membranes.  The  irritation  caused  by 
the  diseased  vertebrge  and  especially  by  accumulations  of  pus 
produce  a  pachymeningitis,  so  that  the  outer  layers  of  the  dura 
are  changed  into  a  thickened  mass  of  young  fibro-plastic  tissue, 
which  either  surrounds  the  dura  like  a  ring  or  presses  it  from 
one  side.  The  nerve  roots  are  also  involved  in  the  morbid 
process,  and  become  more  or  less  thickened,  swollen,  and  in- 
flamed. The  cause  of  pressure  may  be  deposits  of  caseous 
pus,  displaced  fragments  of  bone,  or  protruding  intervertebral 
cartilages. 

Carcinoma  of  the  vertebrae,  whether  primary  or  secondary, 
causes  compression  of  the  cord  when  it  grows  into  the  ver- 
tebral canal.  The  form  of  compression  myelitis  known  as 
parajplegia  dolorosa  with  most  acute  pains  is  then  developed. 

Amongst  other  diseases  of  the  vertebrae  which  occasionally 
cause  compression  of  the  cord  may  be  mentioned  exostoses, 
syphilitic  new  formations,  dry  arthritis  of  the  vertebrae,  and 
thickening  of  the  odontoid  process  of  the  axis. 

External  tumours  of  all  kinds,  such  as  carcinomata,  sarco- 
mata, aneurisms,  and  echinococci,  growing  against  the  verte- 
bral column  and  entering  the  vertebral  canal,  occasion  com- 
pression of  the  cord.  When  the  gradual  compression  gives 
rise   to  transverse   myelitis,    another   characteristic   group   of 


I 


THE   SPINAL   CORD   AND   MEDULLA   OBLONGATA.  353 

symptoms  appears,  which  constitutes  the  second  stage  of  the 
affection.  The  irritation  caused  by  tumours  may  produce 
myelitis  in  the  absence  of  any  compression.  If  the  compression 
be  not  soon  relieved,  secondary  ascending  and  descending 
degenerations  of  the  cord  supervene,  and  then  another  group  of 
characteristic  symptoms  develop,  constituting  the  third  stage 
of  the  disease. 

Slow  compression  of  the  medulla  oblongata  is  caused  by 
tumours  growing  from  the  bones,  periosteum,  meninges,  or  in 
the  surrounding  parts  of  the  brain  and  growing  in  the  direction 
of  the  medulla,  or  by  tumours  growing  in  the  substance  of  the 
pons  or  medulla  itself,  and  aneursims  of  the  arterial  trunks. 
Caries  of  the  occipital  bone  or  of  the  first  two  cervical  vertebrae 
with  consequent  exudation,  abscess,  or  dislocation  of  the 
odontoid  process  may  also  produce  gradual  compression  of  the 
medulla  oblongata. 

The  medulla  is  often  compressed,  too,  by  abnormalities  in 
the  shape  and  size  of  the  bones,  such  as  contraction  of  the 
foramen  magnum  and  enlargement  of  the  odontoid  process. 
Arthritis  deformans  in  the  articulations  between  the  occiput 
and  altas  would  appear  to  be  a  very  rare  cause  of  compression 
of  the  medulla. 

§  578.  Symptoms. 
1.  Slow  Compeession  of  the  Spinal  Cord, 

The  symptoms  of  compression  myelitis  may  be  divided  into 
(a)  extrinsic  and  (6)  intrinsic  symptoms. 

(a)  The  extrinsic  or  prodromal  symptoms  are,  in  addition 
to  the  signs  of  Pott's  curvature  or  tumour,  phenomena  of  irri- 
tation of  the  roots  of  the  spinal  nerves.  The  first  symptoms 
generally  consist  of  severe  girdle  pains,  hyperajsthesia  of  the 
skin  corresponding  to  the  distribution  of  the  pain,  and  eccen- 
tric neuralgiform  pains  generally  fixed  to  one  particular  spot. 
Other  symptoms  generally  present  are  severe  pain  in  the  back, 
local  stiffness,  and  tenderness  of  the  spinous  processes.  The 
neuralgic  pains  are  often  accompanied  by  herpetic  or  bulbous 
eruptions  of  the  skin.  Phenomena  of  motor  irritation  are 
superadded  to  the  sensory  disturbances  in  the  distribution  of 
X 


354!  TRAUMATIC  DISEASES  AND  ABNORMALITIES   OF 

the  nerves  whose  roots  were  first  implicated.  These  consist 
of  twitchings,  spasms,  and  contracture  of  the  muscles  supplied 
by  the  affected  nerves.  The  irritative  motor  symptoms  are 
soon  followed  by  weakness  and  paralysis,  which  is  limited  to 
single  muscles  or  groups  of  muscles,  and  often  accompanied  by 
atrophy  and  loss  of  electrical  excitability.  In  the  paralysis 
caused  by  pressure  on  the  roots  of  the  nerves  reflex  actions  are 
abolished.  The  initial  stage  may  last  months  or  years,  and 
always  precedes  for  some  time  that  of  compression  of  the  cord. 
The  irritative  symptoms  are  absent  in  cases  of  intra-medullary 
tumours. 

(6)  The  Intrinsic  Symptoms. — The  second  stage  of  the 
disease  is  generally  ushered  in  by  paralysis  of  more  or  less 
rapid  development,  usually  in  the  form  of  paraplegia.  The 
paralysis  may  at  times  begin  as  hemiplegia,  and  afterwards 
develop  into  paraplegia.  The  paralysis  may  be  preceded  for  a 
short  time  by  parsesthesise  in  the  lower  half  of  the  body,  such  as 
tingling,  furriness,  sensations  of  burning  or  coldness,  and  girdle 
sensations.  The  order  in  which  the  sensory  and  motor  symptoms 
appear  depends  on  the  direction  in  which  the  pressure  is  made. 
The  paralysed  muscles  are  at  first  flaccid  and  offer  no  resistance 
to  passive  movements,  but  the  cutaneous  reflex  actions  are 
increased  in  the  lower  extremities,  except  when  the  lumbar 
enlargement  is  subjected  to  pressure. 

Paralysis  of  the  rectum  and  bladder  occurs  sooner  or  later 
when  there  is  a  considerable  degree  of  compression,  but  it  is 
usually  a  late  symptom  when  the  lesion  is  situated  in  the  dorsal 
or  cervical  regions.  As  the  disease  progresses  the  muscles  become 
gradually  tense  and  rigid,  and  are  affected  with  twitchings  or 
transient  tonic  spasms.  Contractures  appear,  which  are  at  first 
temporary,  but  soon  become  permanent.  The  lower  extremities 
continue  in  a  permanent  position  of  extension,  which  may  sub- 
sequently give  place  to  flexion. 

The  cutaneous  and  tendinous  reflex  actions  are  now  greatly 
exaggerated,  and  slight  dorsal  flexion  of  one  foot  may  produce 
active  clonic  movements,  or  convulsive  tremors  in  both  the  lower 
extremities.  The  reflex  actions  originating  in  other  parts  are 
also  increased.  The  introduction  of  a  catheter  or  the  evacuation 
of  the  bladder  or  rectum  may  cause  active  jerkings  of  the  limbs, 


THE   SPINAL   CORD   AND   MEDULLA   OBLONGATA,  355 

and  irritation  of  the  inner  side  of  the  thigh  has  been  known 
to  produce  erections  of  the  penis. 

The  sensory  disturbances  are  not  usually  so  well  marked 
as  the  motor,  and  complete  anaesthesia  of  the  paralysed 
parts  is  rare  in  vertebral  caries.  Cancer  of  the  vertebral 
column,  growing  into  the  spinal  canal,  is,  however,  accompanied 
by  pains  of  intense  severity  (Charcot).  These  pains  consist 
of  a  severe  girdle  pain  and  pain  radiating  along  the  distribu- 
tion of  certain  nerves,  as  the  crural  and  sciatic  nerves  when 
the  lumbar  vertebrae  are  affected.  The  skin  to  which  the 
affected  nerves  are  distributed  is  intensely  hyperaesthetic,  so 
that  the  slightest  touch  is  painful.  The  pains  are  constantly 
present  but  are  liable  to  paroxysmal  exacerbations  of  intense 
severity,  which  are  difficult  to  allay  even  by  large  doses 
of  narcotics.  Patches  of  anaesthesia  may  be  observed  in  the 
skin  to  which  the  affected  nerves  are  distributed,  while  the  pain 
still  continues  unabated  (ancesthesia  dolorosa).  The  symp- 
toms of  compression  of  the  cord  are  after  a  time  superadded  to 
these  sensory  disturbances,  and  then  the  condition  has  been 
called  paraplegia  dolorosa.  On  local  examination  of  the  ver- 
tebral column  an  excurvation  of  the  spine  may  be  observed, 
and  the  spinous  processes  in  this  region  may  be  exceedingly 
tender  to  pressure  or  percussion.  Inasmuch  as  cancer  of  the 
vertebral  column  is  always  secondary,  the  presence  of  a  can- 
cerous tumour  in  some  other  part  of  the  body,  or  of  the  can- 
cerous cachexia,  greatly  aids  the  diagnosis. 

Trophic  disturbances  are  not  prominent  in  compression 
myelitis.  When  the  lumbar  or  cervical  enlargement  is  affected, 
or  when  secondary  inflammation  of  the  grey  substance  extends 
upwards  or  downwards  to  these  parts,  the  muscles  of  the  cor- 
responding extremities  undergo  rapid  atrophy,  attended  by  loss 
of  faradic  contractility  and  the  reaction  of  degeneration.  In 
some  cases  a  few  of  the  muscles  become  atrophied,  while  others 
undergo  contracture.  An  eruption  of  herpes  sometimes  en- 
circles one-half  of  the  body  on  a  level  with  the  lesion.  In 
severe  cases,  and  in  the  terminal  period  of  ordinary  cases, 
bed-sores  and  cystitis  supervene,  with  their  usual  deleterious 
consequences. 

The  subsequent  course  of  the  disease  is  not  uniform.     The 


356  TRAUMATIC   DISJ3ASES  AND  ABNORMALITIES   OF 

less  severe  cases  continue  for  a  long  time  without  change,  but 
afterwards  improvement  may  gradually  take  place.  The  anaes- 
thesia first  diminishes,  the  functions  of  the  bladder  are  better 
regulated,  and  after  a  time  motor  power  gradually  returns.  In 
severe  cases  the  symptoms  grow  worse,  the  paraplegia  becomes 
complete,  the  bladder  and  rectum  are  paralysed,  cystitis,  bed- 
sores, and  pyaemia  supervene,  and  soon  cause  death. 

§  579.  Varieties. — The  symptoms  differ  considerably  accord- 
ing to  the  situation  of  the  lesion. 

(a)  Compression  of  the  Cervical  Region  of  the  Spinal  Cord. — When  the 
upper  part  of  the  cervical  region  is  affected  the  disease  often  begins  by 
pain  in  the  occiput,  stiffness  of  the  wliole  neck,  obliquity  of  the  head,  and 
inability  to  nod  or  to  rotate  the  head.  The  paralysis  often  begins  in  the 
upper  extremities,  while  the  lower  are  wholly  or  comparatively  unaffected ; 
but  at  a  later  period  the  extremities  become  paralysed,  the  reflex  actions 
being  exaggerated  in  all  the  -extremities.  Paralytic  myosis  or  spastic 
mydriasis  may  be  present  on  one  or  on  both  sides.  Other  symptoms  which 
have  been  observed  are  repeated  vomiting,  difficulty  of  swallowing,  inces- 
sant hiccough,  retardation  of  the  pulse,  which  may  beat  only  48  to  20  times 
in  the  minute,  fainting  fits  with  temporary  arrest  of  the  heart's  action, 
and  occasionally  epileptic  attacks. 

If  the  cervical  enlargement  be  affected,  the  initial  symptoms  of  pain, 
anaesthesia,  spasm,  paralysis,  and  atrophy  are  localised  in  the  upper 
extremities,  and  the  symptoms  appear  in  the  lower  extremities  at  a  later 
period.  Oculo-pupillary  symptoms,  disturbances  of  respiration,  and 
retarded  pulse  may  also  occur.  Reflex  action  may  be  abolished  in  the 
upper  extremities. 

(&)  Compression  of  the  Dorsal  Region  of  the  Cord. — The  dorsal  region  is 
the  most  frequent  seat  of  compression.  The  symptoms  are  girdle  pains, 
intercostal  neuralgia  at  different  levels  of  the  trunk,  paraplegia  up  to  the 
corresponding  level,  reflex  actions  in  the  lower  extremities  retained  or 
increased,  and  the  nutrition  of  the  muscles  and  their  electrical  excitability 
normal. 

(c)  Compression  of  the  Lumbar  Region  of  the  Cord, — If  the  lumbar 
region  be  affected,  the  paralysis  is  confined  to  the  lower  extremities, 
bladder,  and  rectum.  The  initial  symptoms  are  localised  in  the  lower 
extremities,  where  reflex  actions  are  abolished,  and  the  muscles  are  per- 
manently relaxed  and  atrophied  and  exhibit  the  reaction  of  degeneration. 
If  one  lateral  half  of  the  cord  be  compressed,  the  characteristic  symptoms 
of  Brown- Se'quard's  unilateral  lesion  appear. 


THE  SPINAL   CORD  AND  MEDULLA  OBLONGATA.  357 

2.  Slow  Compression  of  the  Medulla  Oblongata. 
The  initial  symptoms  are  caused  by  irritation  and  subsequent 
paralysis  of  the  roots  of  the  nerves  of  the  medulla  and  pons. 
Those  of  irritation  first  show  themselves,  consisting  of  neural- 
giform pains  in  the  region  of  the  trigeminus,  either  on  one  or 
both  sides,  and  buzzing  in  the  ears.  The  motor  irritative  symp- 
toms consist  of  twitchings  of  the  facial  muscles,  transitory 
cramps  in  the  tongue  and  lips,  and  occasionally  clonic  or  tonic 
contractions  in  the  extremities.  When  the  medulla  oblongata 
is  seriously  compressed,  epileptiform  convulsions,  vomiting,  diz- 
ziness, and  hiccough  are  produced.  The  second  stage  is  ushered 
in  by  paralysis  of  the  seasory  and  motor  nerves.  There  may 
be  ansesthesia  in  the  region  of  the  trigeminus,  often  accom- 
panied by  intense  pain  and  neuroparalytic  ophthalmia.  There 
may  be  loss  of  taste,  or  deafness  on  one  or  on  both  sides,  and 
one  or  more  of  the  cranial  motor  nerves  may  be  paralysed,  while 
the  paralysed  muscles  undergo  atrophy,  lose  their  faradic  con- 
tractility, and  manifest  the  reaction  of  degeneration.  After  a 
time  a  true  bulbar  paralysis  appears,  the  extremities  become 
paralysed,  and  disorders  of  respiration  supervene.  The  symp- 
toms begin  sometimes  so  suddenly  as  to  simulate  embolus  or 
thrombosis.  These  acute  symptoms  are  caused  by  a  rapidly 
developing  bulbar  myelitis,  or  by  oedema,  thrombosis,  or  haemor- 
rhage. The  optic  nerves  are  not  affected  unless  the  tumour 
be  of  large  size,  and  probably  then  only  when  it  is  accompanied 
by  effusion  into  the  ventricles  of  the  brain. 

§  580.  Course,  Duration,  and  Termination. — The  course 
of  the  disease  depends  on  the  nature  of  the  primary  lesion. 
Meningeal  and  intra-medullary  tumours,  as  well  as  carcinoma 
or  other  malignant  tumours  of  the  vertebrae,  are  always  fatal. 
In  most  cases  of  vertebral  caries,  on  the  other  hand,  the  course 
is  comparatively  favourable.  Many  cases,  however,  progress 
slowly  with  remissions  and  exacerbations  to  a  fatal  termination. 
In  other  cases  the  recovery  is  incomplete,  partial  paralysis, 
contractures,  muscular  atrophy,  and  ansesthesia  remain,  and 
relapses  are  frequent. 

§  581.  Morbid  Anatomy. — The  meninges  are  often  hyper- 


358  TRAUMATIC  DISEASES  AND  ABNORMALITIES  OF 

semic,  opaque,  and  adherent  to  the  neighbouring  parts,  or 
covered  with  deposits  of  various  thickness.  The  nerve  roots 
may  be  closely  united  with  the  tumour  or  exudation.  At  first 
they  are  swollen  and  hypersemic,  and  their  fibres  are  in  a 
state  of  fatty  degeneration.  At  a  later  period  the  roots  are 
atrophied,  pale  grey,  degenerated,  and  nearly  reduced  to  con- 
nective tissue. 

The  substance  of  the  spinal  cord  is  rendered  more  or  less  flat 
and  thin  at  the  point  compressed,  and  it  may  be  reduced  to  the 
size  of  a  small  quill.  The  compression  is  sometimes  greater 
anteriorly,  sometimes  greater  posteriorly,  at  other  times  from 
one  or  other  side,  so  that  the  cord  assumes  a  distorted  and 
irregular  appearance.  The  compressed  spot  varies  in  length, 
and  is  usually  softened,  although  it  may  be  sclerosed  in  long- 
standing cases.  In  chronic  cases  the  usual  ascending  and 
descending  changes  occur  above  and  below  the  level  of  the 
lesion. 

A  microscopical  examination  of  the  spinal  cord  reveals  the 
appearances  which  usually  characterise  a  chronic  interstitial 
myelitis.  .In  addition  to  the  characteristic  phenomena  of 
ascending  and  descending  sclerosis,  a  myelitis  of  the  central 
grey  substance  may  often  be  discovered  for  a  considerable  dis- 
tance above  and  below  the  seat  of  lesion.  In  favourable  cases 
restoration  and  almost  complete  recovery  may  take  place,  and 
consequently  the  nerve  elements  must  be  to  some  extent  restored 
at  the  point  of  compression.  Charcot  and  Michaud  examined  a 
case,  fatal  from  other  causes,  in  which  recovery  from  compression 
myelitis  had  occurred.  The  transverse  section  of  the  cord 
at  the  seat  of  compression  was  much  smaller  than  the  other 
portions  of  the  cord,  and  looked  grey  and  degenerated. 
Microscopical  examination  showed  that  there  was  an  excess  of 
connective  tissue  at  the  seat  of  compression,  through  which  a 
considerable  number  of  normal  though  slender  nerve  fibres 
passed.  The  grey  substance  was  much  reduced  in  size,  but 
some  healthy  ganglion  cells  were  observed  in  it.  It  is  probable 
that  the  axis  cylinders  of  all  the  fibres  were  not  destroyed,  and 
that  they  had  assumed  a  new  medullary  sheath  on  the  pressure 
being  removed. 

The  medulla  oblongata  may  be  flattened,  either  on  one  or 


THE  SPINAL  CORD  AND   MEDULLA  OBLONGATA.  359 

both  sides,  turned  on  its  axis,  and  distorted  in  various  ways. 
The  tissue  of  the  medulla  is  ansemic  and  softened,  while  extra- 
vasations of  blood  are  often  observed.  The  roots  of  the  cranial 
nerves  may  be  compressed  and  flattened,  and  the  nerves  then 
undergo  degenerative  atrophy.  The  pyramidal  tracts  of  the 
lateral  columns  and  the  columns  of  Tiirck  may  undergo 
descending  degeneration  throughout  the  entire  length  of  the 
spinal  cord. 

§  582.  Diagnosis. — The  initial  symptoms  caused  by  com- 
pression of  the  roots  of  the  nerves  are  of  importance  in  the 
diagnosis  of  the  affection,  and  in  ordinary  cases  confirmation  of 
the  diagnosis  will  be  obtained  from  the  external  appearances 
presented  by  the  primary  disease.  In  Pott's  curvature  the 
gradual  formation  of  angular  kyphosis,  and  the  history  of  the 
case  generally,  afford  indications  of  the  nature  of  the  affection 
which  are  unmistakable. 

In  carcinoma  of  the  vertebrae  the  girdle  sensation  and  other 
eccentric  pains  are  of  the  most  agonising  severity ;  they  occur 
in  nocturnal  paroxysms,  and  great  hypersesthesia  usually  exists 
in  the  painful  region.  If  primary  cancer  can  be  found  in 
another  organ,  or  there  be  a  general  cachexia,  the  diagnosis  will 
be  less  difficult. 

The  recognition  of  the  rarer  causes  of  compression  of  the  cord, 
such  as  exostoses,  syphilitic  new  formations,  and  aneurisms,  is 
made  from  the  general  symptoms  of  the  respective  diseases. 

Slow  compression  of  the  medulla  oblongata  may  be  suspected 
when  symptoms  of  irritation  in  the  regions  of  distribution  of 
some  of  the  bulbar  nerves  are  followed  by  those  of  sensory  or 
motor  paralysis,  and  when  electrical  examination  shows  that 
the  motor  paralysis  is  of  peripheral  origin.  The  diagnosis  is 
still  further  confirmed  when  the  patient  suffers  from  giddiness, 
violent  headache,  severe  vomiting,  epileptoid  convulsions,  and 
when  twitching  and  subsequent  paralysis  and  contractures  occur 
in  the  extremities,  more  especially  when  the  distribution  of  these 
in  the  latter  is  unsymmetrical.  Cases  of  compression  of  the  an- 
terior pyramids  of  the  medulla  may  closely  resemble  spastic 
spinal  paralysis.  The  points  of  distinction  between  the  two 
affections  are  that  the  paralysis  begins  suddenly  in  compression. 


860  TRAUMATIC   DISEASES  AND  ABNORMALITIES   OF 

the  upper  extremities  are  usually  affected  before  the  lower, 
and  bulbar  paralysis  sooner  or  later  Supervenes ;  while  in  spastic 
paralysis  the  commencement  of  the  paralysis  is  slow  and 
gradual,  the  lower  extremities  are  usually  affected  before  the 
upper,  and  bulbar  symptoms  probably  never  appear  in  primary 
lateral  sclerosis. 

§  583.  Prognosis. — In  most  cases  of  slow  compression  of  the 
cord  the  prognosis^  is  unfavourable.  Cases  due  to  the  pressure 
of  syphilitic  formations,  peri-meningeal  exudations,  and  verte- 
bral caries  often  recover.  In  young,  well-nourished  persons, 
who  are  not  scrofulous,  recovery  with  slight  deformity  of  the 
vertebral  column  generally  takes  place.  In  many  cases,  how- 
ever, recovery  is  imperfect,  and  a  certain  amount  of  paralysis  of 
the  lower  extremities  with  contractures  remains. 

The  prognosis  of  slow  compression  of  the  medulla  oblongata 
is  always  unfavourable. 

§  584.  Treatment. — In  severe  cases  the  treatment  must  be 
altogether  palliative,  and  directed  to  the  relief  of  pain  and 
other  discomforts. 

The  most  promising  cases  for  treatment  are  those  of  Pott's 
disease.  In  them  rest  in  bed  for  months  is  necessary,  in  order 
to  maintain  the  spine  in  a  condition  of  repose.  Various  kinds 
of  apparatus  have  been  used  for  the  support  and  protection 
of  the  spine.  The  best  apparatus  consists  of  the  plaster  of 
Paris  bandage,  introduced  by  Dr.  Sayre,  but  I  must  refer  the 
reader  to  surgical  works  for  a  full  description  of  the  method 
of  application. 

The  internal  treatment  should  be  that  adapted  to  scrofulous 
patients  generally,  consisting  of  fresh  air,  cod-liver  oil,  cream, 
iron,  and  quinine.  The  hot  iron  has  been  recommended  by 
Charcot  and  others  to  be  applied  every  two  weeks  on  each  side 
of  the  curvature. 

In  slow  compression  of  the  medulla  oblongata,  treatment  is 
of  very  little  avail,  unless  the  case  be  one  of  caries,  or  syphilitic 
tumour. 


THE  SPINAL   CORD  AND  MEDULLA  OBLONGATA.  361 

(IIL)  HEMIPLEGIA  ET  HEMIPARAPLEGIA  SPINALIS. 

Unilateral  Lesion  of  the  Spinal  Cord. 

Brown-Siquard's  Spinal  Paralysis. 

§  585.  Definition. — The  symptoms  which  are  grouped  to- 
gether under  the  name  of  unilateral  spinal  paralysis  are  mainly 
characterised  by  unilateral  motor  paralysis  and  bypergestbesia 
on  the  side  of  the  lesion,  anaesthesia  on  the  opposite  side,  and 
local  symptoms  caused  by  implication  of  the  roots  of  the  nerves 
on  a  level  with  the  primary  lesion. 

§  586.  Etiology. — The  symptoms  depend  not  upon  the  nature 
of  the  lesion,  but  upon  its  localisation  in  one  lateral  half  of  the 
spinal  cord,  so  that  it  is  unnecessary  to  give  a  detailed  account 
of  all  the  causes  of  the  affection.  The  penetration  of  the  ver- 
tebral canal  by  pointed  instruments  constitutes  the  most  fre- 
quent cause.  Compression  of  the  cord  from  meningeal  tumours, 
fractures  or  dislocation  of  the  vertebrae,  meningeal  haemorrhage, 
intra-medullary  tumours,  haemorrhage  into  the  substance  of  the 
cord,  and  circumscribed  sclerosis  may  also  give  rise  to  the 
symptoms  of  unilateral  spinal  paralysis. 

§  587.  Symptoms.  —  The  symptoms  of  unilateral  spinal 
paralysis  may  be  developed  insidiously  and  gradually,  or  quite 
suddenly,  the  mode  of  invasion  depending  of  course  on  the 
nature  of  the  lesion.  The  most  prominent  feature  of  the 
affection  is  a  motor  paralysis,  which  is  unilateral,  and  which 
may  only  involve  one  leg  (hemiparaplegia),  or,  if  the  lesion 
be  situated  high  up,  may  also  implicate  the  arm  of  the  same 
side  (spinal  hemiplegia).  The  muscles  on  the  paralysed  side 
usually  undergo  early  and  rapid  atrophy,  and  their  faradic 
excitability  is  diminished.  The  side  opposite  to  the  seat  of  the 
lesion  is  either  free  from  paralysis  or  is  only  affected  to  a  slight 
degree. 

Evidences  of  vaso-motor  paralysis  are  generally  found  on  the 
side  of  the  lesion,  especially  if  the  affection  has  been  rapidly 
developed.  The  temperature  of  the  paralysed  limbs  is  usually 
raised  to  the  extent  in  1*8°  F.  or  more,  although  it  may  be  lower 
than  natural  when  the  disease  has  existed  for  some  time. 


362  TRAUMATIC  DISEASES  AND   ABNORMALITIES   OF 

Muscular  sensibility  and  muscular  sense  are  usually  dimi- 
nished on  the  affected  side,  but  all  forms  of  cutaneous  seosibility, 
instead  of  being  diminished,  are  greatly  increased.  Impressions 
of  touch,  temperature,  and  pain  are  felt  with  great  acuteness,  and 
there  is  an  increased  power  of  localising  tactile  sensations.  At 
times,  however,  the  hypersesthesia  is  limited  to  a  few  only  of  the 
forms  of  cutaneous  sensibility.  The  hypereesthetic  region  of  skin 
is  usually  bounded  by  an  anaesthetic  zone,  which  corresponds  with 
the  height  and  longitudinal  extent  of  the  lesion  in  the  spinal 
cord ;  and  a  narrow  hypersesthetic  zone  which  extends  to  the 
opposite  side  may  sometimes  be  detected  above  the  ansesthetic 
belt.  The  state  of  reflex  action  on  the  paralysed  side  varies. 
It  has  been  found  increased  by  Paoluzzi  and  Riegel,  and 
diminished  by  Brown-Sequard,  Bazire,  and  others.  Not  many 
observations  have  hitherto  been  made  with  respect  to  the  state 
of  the  reflex  irritability  of  the  tendons,  but  Erb  found  it  in- 
creased in  one  case. 

There  either  are  no  motor  disturbances,  or  they  are  only  of 
slight  degree  on  the  side  opposite  the  lesion,  and  both  the 
muscular  sense  and  the  electro-muscular  sensibility  are  retained. 
There  is  more  or  less  complete  anaesthesia  of  the  skin.  Some 
forms  of  sensibility  may  at  times  be  involved  to  a  greater 
extent  than  others.  The  anaesthesia  extends  to  the  median 
line  of  the  body,  and  it  is  often  bounded  above  by  a  slightly 
hypersesthetic  region,  corresponding  to  a  similar  zone  on  the 
opposite  side.  There  are  no  vaso-motor  disturbances  on  this 
side,  and  reflex  action  is  usually  normal,  although  it  has  occa- 
sionally been  found  increased  (Brown-Sequard).  The  patient 
sometimes  complains  of  a  painful  feeling  of  constriction  on  a 
level  with  the  lesion,  along  with  various  painful  sensations,  such 
as  burning,  darting,  and  boring  pains,  which  may  at  times  be 
more  prominent  on  the  anassthetic,  at  other  times  on  the  hyper- 
sesthetic and  paralysed  side,  and  occasionally  occurs  on  both 
sides.  Acute  traumatic  cases  are  usually  associated  at  first 
with  retention  or  incontinence  of  urine,  but  after  a  time  only 
a  certain  amount  of  weakness  of  the  sphincters  of  the  bladder  and 
rectum  remains.  The  sexual  functions  are  at  times  unaffected, 
and  at  other  times  more  or  less  weakened. 

Acute  bed-sore  may  appear  on  the  anaesthetic,  and  inflam- 


THE  SPINAL   CORD  AND  MEDULLA  OBLONGATA.  363 

mation  of  the  knee-joint  on  the  paralysed  side,  while  well- 
marked  ataxia  may  be  observed  on  the  return  of  motor  power 
in  the  paralysed  leg  (Joffroy  and  Solmon). 

§  588.   Varieties  of  Unilateral  Paralysis. 
The  symptoms  differ  considerably,  according  to  the  level  at 
which  the  lesion  is  situated  in  the  cord. 

(1)  In  a  unilateral  lesion  of  the  lumbar  enlargement  of  the  cord  an 
ansesthetic  zone  may  be  found  on  the  paralysed  side,  corresponding  to  the 
area  of  distribution  of  one  or  more  of  the  lumbar  nerves,  in  addition  to  the 
other  characteristic  unilateral  symptoms.  This  area  is  not  always  in  the 
form  of  a  belt,  and  may  be  situated  round  the  abdomen,  in  the  region  of  the 
groin,  or  over  the  anterior  surface  of  the  thigh,  so  that  from  an  imperfect 
examination  one  might  be  led  to  believe  that  the  anaesthesia  was  diffused 
over  the  lower  extremities. 

(2)  Unilateral  lesions  of  the  dorsal  portion  of  the  cord  give  rise  to  the 
most  characteristic  symptoms  of  the  disease,  as  already  described. 

(3)  In  unilateral  lesions  of  the  cervical  portion  of  the  cord  the  grouping 
of  the  symptoms  varies  greatly,  according  to  the  level  at  vyhich  the  lesion  is 
situated  and  its  longitudinal  extent.  It  is  manifest  that  the  distribution 
of  the  motor  and  sensory  disturbances  will  differ  according  as  the  upper  or 
lower  roots  of  the  brachial  plexus  are  involved  in  the  lesion,  and  according 
as  the  cilio-spinal  region  is  or  is  not  implicated. 

In  the  lower  extremities  and  trunk  the  motor  and  sensory  disturbances 
are  the  same  as  when  the  dorsal  portion  is  implicated.  In  the  upper  ex- 
tremities on  the  side  of  the  lesion  a  certain  number  or  all  of  the  muscles 
are  paralysed,  there  is  hyperaesbhesia  of  certain  parts  of  the  skin  mingled 
with  anaesthesia  of  other  regions  or  for  certain  varieties  of  sensation. 
On  the  side  opposite  to  the  lesion  there  is  no  paralysis,  but  there  is  more 
or  less  complete  anaesthesia  over  the  whole  skin  below  the  lesion,  or  over 
special  territories. 

The  neck  and  head  on  the  side  of  the  lesion  manifest  anaesthesia  and 
hypersesthesia  of  certain  areas  of  the  skin  and  paralysis  of  the  vaso-motor 
and  oculo-pupillary  fibres,  giving  rise  to  increased  temperature  of  that 
side  of  the  head  and  body,  heightened  sensibility,  narrowing  of  the  palpe- 
bral fissure,  and  contraction  of  the  pupil.  On  the  side  opposite  the  lesion 
there  is  usually  anaesthesia  of  the  neck,  along  with  a  narrow  zone  of  hyper- 
sesthesia, and  a  normal  condition  of  the  face  and  eye. 

§  589.  Morbid  Physiology. — It  is  almost  needless  to  mention 
that  unilateral  section  will  divide  the  columns  of  Tiirck,  the 
anterior  root-zones,  the  pyramidal  tracts  and  direct  cerebellar 
fibres  of  the  lateral  columns,  the  posterior  root-zones  and  the 


364 


TRAUMATIC   DISEASES  AND  ABNORMALITIES   OF 


Fig.  182. 


columns  of  GoU,  and  the  anterior  and  posterior  horns  of  grey- 
matter;  and  when  the  lesion  is  of  considerable  longitudinal 
extent  a  considerable  number  of  the  anterior  and  posterior 
nerve  roots  may  be  destroyed. 

Division  of  the  pyramidal  tracts  in  the  anterior  and  lateral 
columns  will  sever  the  muscles  below  the  point  of  the  lesion 
from  the  cortex  of  the  brain,  hence  there  will  be  complete  loss 
of  voluntary  power  below  and  on  the  same  side  as  the  lesion. 
When  the  lesion  is  permanent,  the  pyramidal  tracts  undergo 
secondary  descending  degeneration,  and,  after  a  time,  increased 

muscular  tension  and  contrac- 
tures are  superadded  to  the 
motor  paralysis.  Recent  in- 
vestigations have  apparently 
proved  that  the  vaso-motor 
tracts  also  run  in  the  lateral 
columns,  thus  division  of  these 
would  produce  vaso-motor  dis- 
turbances on  the  side  of  the 
lesion. 

Division  of  the  anterior  root- 
zone  and  direct  cerebellar  tract 
is  not  known  to  give  rise  to  any 
symptoms,  probably  because 
the  result  of  injury  to  these 
parts  is  masked  by  the  presence 
of  motor  paralysis.  Similar 
remarks  apply  to  injury  of  the 
columns  of  Goll  and  the  pos- 
terior root-zones,  but  it  is  in- 
teresting to  find  that  Joffroy 
and  Solmon  observed  the  occur- 
rence of  well-marked  ataxy  on 
the  return  of  motor  power  in 
the  paralysed  extremity, caused 
doubtless  by  the  injury  of  the 
posterior  root-zone  of  that  side. 
Division  of  the  grey  matter 
of  the  one  half  of  the   cord 


Fig.  182  (After  Erb).  Diagram  of  the 
Course  of  the  principal  Conducting 
Paths  ivithin  the  Cord. — 1  and  1', 
The  motor  and  vaso-motor  tracts, 
passing  through  the  anterior  root  (v), 
and  remaining  on  the  same  side  of 
the  cord ;  2  and  2',  Tracts  which 
conduct  the  muscular  sensibility, 
also  passing  through  the  anterior 
roots,  and  remaining  on  the  same 
side  of  the  cord ;  3  and  3',  The  tracts 
which  conduct  sensory  impressions 
of  touch,  temperature,  pain,  and 
tickling.  These  enter  the  cord 
through  the  posterior  roots,  and 
cross  to  the  other  side,  and  pursue 
their  course  upwards  on  that  side. 
Section  of  the  right  half  of  the 
cord  (a)  must  interrupt  c(jnduction 
through  the  motor,  vaso-motor,  and 
musculo-sensory  tracts  (1  and  2)  on 
the  right  side,  and  the  cutaneous 
sensory  tracts  on  the  left  side  (3'). 


THE   SPINAL   CORD  AND   MEDULLA  OBLONGATA. 


865 


Fig.  183. 


produces  anaesthesia  of  one  half  of  the  body  below  the  level  of 
the  lesion  on  the  opposite  side,  showing  that  the  sensory 
fibres  cross  over  to  the  opposite  side  soon  after  their  entrance 
into  the  cord.  The  fibres  conducting  impressions  of  touch, 
temperature,  pain,  and  tickling  decussate  with  those  of  the 
other  side  very  near  their  point  of  entrance  into  the  spinal 
cord,  and  run  to  the  brain  in  the  opposite  side  of  the  cord. 
Those  concerned  in  the  phenomena  of  muscular  sense  are 
supposed  to  enter  the  cord  with  the  anterior  roots,  and,  like  the 
motor  tracts,  run  through  the  cord  on  their  own  side  of  the 
body. 

Brown-S^quard  states  that 
the  conducting  tracts  of  the 
various  forms  of  cutaneous 
sensibility  cross  at  different 
heights,  those  concerned  in 
the  sensation  of  temperature 
crossing  somewhat  earlier  than 
the  rest.  He  also  thinks  that 
they  are  separated  from  one 
another  in  their  further  course, 
each  lying  in  certain  definite 
segments  of  the  cord,  and  that 
the  sensitive  tracts  of  the 
lower  extremities  lie  behind 
those  of  the  upper  in  the 
cervical  portion  of  the  cord. 
The  centripetal  fibres  con- 
cerned in  reflex  action  have  a 
crossed  course  within  the  cord 
(Miescher), 

It  is  evident,  therefore,  that 
section  of  one  half  of  the  spinal 
cord  must  cause  ansesthesia  of 
the  opposite  side  for  sensations 
of  touch,  pain,  temperature, 
and  tickling,  and  loss  of  the 
muscular  sense,  and  motor 
paralysis  on  the  same  side. 


Fig.  183  (After  Erb).  Diagram  of  the 
cutaneous  symptoms  in  unilateral 
lesion  of  the  dorsal  portion  of  the 
spinal  cord  on  the  left  side. — The 
diagonal  shading  (a)  signifies  motor 
and  vaso-motor  paralysis  ;  the  verti- 
cal shading  (6,  d)  signifies  cutaneous 
ansesthesia;  the  dotted  shading  (a,  c) 
indicates  hypersesthesia  of  the  skin. 


366  TRAUMATIC  DISEASES  AND  ABNORMALITIES   OF 

The  phenomena  wliich  result  from  section  of  one  half  of  the 
spinal  cord  are  well  illustrated  by  Fig.  183. 

Anatomists  have  described  a  middle  and  a  superior  crossing  of  sensory 
fibres,  both  of  which  are  supposed  to  take  place  in  the  medulla  oblongata. 
The  sensory  decussation  of  the  pyramids  described  by  Meynert  consists  of 
fibres  which  issue  from  the  nuclei  of  the  cuneate  and  slender  fasciculi. 
These  fibres  pursue  an  arcuate  course  around  the  central  grey  column,  and 
become  mixed  with  the  crossing  fibres  of  the  lateral  column.  Flechsig, 
however,  asserts  that  these  fibres  curve  round  the  olivary  body  of  the 
same  side  and  enter  into  its  substance.  The  most  recent  researches  with 
regard  to  the  sensory  crossing  have  been  undertaken  by  MM.  Debove 
and  Gombault.  Their  observations  were  made  in  a  case  of  amyotrophic 
lateral  sclerosis,  in  which  the  motor  fibres  of  the  anterior  pyramids  of  the 


Fig.  184. 


\M 


FSA^ 


•i 


A 


^■^ 


Fig.  184  (After  Debove  and  Gombault).  Section  of  the  Anterior  Pyramid  (P)  of 
the  Medulla  Oblongata,  on  a  level  with  the  middle  part  of  the  crossing  of  the 
Sensory  Fibres, — FS,  Sensory  fibres ;  FSA,  Posterior  and  external  sensory 
fasciculus  wliich  does  not  penetrate  into  the  substance  of  the  pyramid ;  E, 
Crossing  of  the  sensory  fibres ;  O,  Nucleus  of  the  pyramid ;  Z,  Stratum  zonale. 

medulla  had  undergone  degeneration.  The  sensory  fibres  become  sub- 
divided into  small  fasciculi,  which  penetrate  into  the  posterior  and 
external  portion  of  the  anterior  pyramids.  The  fibres  then  curve  up- 
wards and  become  inseparably  mixed  with  the  motor  fibres.  A  little  higher 
up  some  of  these  fibres  become  mixed  with  the  fibres  of  the  stratum 
zonale.  These  fibres  are  very  well  seen  in  some  of  my  sections  of  the 
medulla  oblongata  from  a  nine  months  human  embryo,  but  I  have  always 
regarded  them  as  being  derived  from  the  external  portion  of  the  inner 
division  of  the  inferior  peduncle  of  the  cerebellum,  and  I  am  by  no 
means  satisfied  that  their  functions  are  sensory. 

The  relations  of  reflex  action  to  unilateral  section  of  the  cord  are  not 
yet  well  ascertained,  and  the  condition  appears  to  vary  in  different 
animals.  According  to  the  experiments  of  Woroschiloff",  it  would  appear 
that  tbe  fibres  which  check  or  control  reflex  action  in  a  lower  extremity 


THE  SPINAL  CORD   A.ND  MEDULLA   OBLONGATA.  867 

run  their  course  principally  in  the  same  half  of  the  cord,  while  those 
which  call  forth  reflex  action  run  chiefly  in  the  opposite  half.  Wheji 
the  lesion  extends  longitudinally,  so  as  to  destroy  several  of  the  posterior 
root  fibres  before  their  crossing,  there  will  be  an  antesthetic  zone  on  the 
paralysed  side  lying  above  the  hypertesthetic  region,  and  corresponding  in 
width  to  the  number  of  fibres  destroyed  by  the  lesion.  Implication  of 
the  cilio-spinal  region  causes  vaso-motor  disturbances  in  the  face  and 
side  of  the  head,  paralytic  myosis,  and  narrowing  of  the  palpebral  fissure  on 
the  side  of  the  lesion. 

The  narrow  hypersesthetic  zone  sometimes  observed  above  the  anaes- 
thetic belt  is  explained  by  Brown-Sequard  on  the  ground  that  the  des- 
cending fibres  of  the  posterior  roots  fall  within  the  range  of  the  lesion. 
Be  has,  however,  recently  obtained  a  curious  result  by  making  a  section 
of  one  half  of  the  pons  in  animals  immediately  in  front  of  the  middle 
peduncle  of  the  cerebellum,  followed  after  a  time  by  section  of  the  other 
half.  After  section  of  the  first  half  of  the  pons,  there  is  hyperaesthesia  of 
one  half  of  the  body,  on  the  side  of  the  lesion,  and  anaesthesia  of  the 
opposite  half,  the  sensory  disturbances  being  specially  well  marked  in  the 
lower  extremities.  In  an  animal  which  had  undergone  hemisection  of  the 
right  side  of  the  pons,  and  which  was  consequently  hypersesthetic  on  the 
right  side,  hemisection  of  the  left  side  of  the  pons  produced  a  reversal  of 
the  sensory  phenomena,  so  that  the  left  half  of  the  body  became  hyper- 
sesthetic and  the  right  anaesthetic.  This  curious  result  shows  that  the 
phenomena  of  sensory  conduction  are  by  no  means  so  definite  or  so  well 
ascertained  as  those  of  motor  conduction. 

The  existence  of  cutaneous  hyperaesthesia  on  the  side  of  the  lesion  is 
usually  explained  on  the  supposition  that  it  is  a  phenomenon  of  irritation 
caused  by  the  secondary  inflammation  surrounding  the  lesion  ;  but  after 
the  result  obtained  by  Brown-Se'quard  it  will  probably  be  better  to  suspend 
our  judgment  with  regard  to  it  in  the  meantime.  It  does  not,  however, 
appear  to  me  that  much  light  is  thrown  upon  the  point  by  postulating^ 
like  Brown-Sequard,  the  existence  in  the  cerebro-spinal  axis  of  special 
centres  possessed  of  inhibitory  and  dynamogenic  functions. 

§  590.  Course,  Duration,  and  Termination. — The  course  of 
the  symptoms  depends  chiefly  upon  the  nature  of  the  lesion 
which  has  caused  the  affection  and  varies  greatly  in  different 
cases.  The  lesion  as  a  rule  extends  both  longitudinally  and 
transversely,  and  only  remains  stationary  in  rare  cases.  When 
the  lesion  extends  transversely,  paraplegia  and  the  other  symp- 
toms of  transverse  myelitis  result.  As  the  inflammation  sub- 
sides the  symptoms  of  the  unilateral  lesion  may  recur,  and  may 
then  continue  unchanged  for  many  years.  Complete  recovery 
has  occasionally  been  observed  in  traumatic  unilateral  lesions,  and 


368  TRAUMATIC   DISEASES  AND  ABNORMALITIES   OF 

according  to  Brown-S^quard  the  motor  disturbances  disappear 
earlier  and  more  completely  than  those  of  sensation.  In  tumour 
the  disease  generally  extends  transversely,  giving  rise  to  para- 
plegia. 

§  591.  Diagnosis. — Hemiparaplegia,  from  lesion  of  one  side 
of  the  Cauda  equina,  may  be  distinguished  from  that  caused  by 
unilateral  lesion  of  the  cord  by  the  circumstances  that  in  the 
former  the  paralysis  and  anaesthesia  are  on  the  same  side,  and 
that,  as  a  rule,  only  certain  nerve  territories  of  the  lower  extre- 
mities are  affected. 

The  hemiplegic  form  of  lateral  sclerosis  is  readily  recognised 
by  the  absence  of  all  disturbances  of  sensation  and  of  any 
disorder  of  the  bladder  or  rectum.  Cerebral  hemiplegia  may 
be  distinguished  from  the  spinal  form  by  the  fact  that  in  the 
former  there  is  either  no  disturbance  of  sensation  or  that  it  is 
to  be  found  on  the  same  side  as  the  paralysis,  and  that  there  is 
unilateral  paralysis  of  the  face  and  tongue.  The  nature  of  the 
lesion  is  not  readily  ascertained  in  the  absence  of  any  distinct 
injury,  and  consequently  the  diagnosis  must  rest  upon  general 
pathological  principles. 

§  592.  Prognosis. — The  prognosis  depends  entirely  upon  the 
nature  of  the  lesion  which  causes  the  symptoms.  The  majority 
of  traumatic  cases  end  in  recovery  with  proper  care  and  treat- 
ment. 

§  593.  Treatment — The  treatment  is  generally  the  same  as 
that  which  is  applicable  to  wounds  of  the  spinal  cord  and  to 
chronic  myelitis. 

(IV.)    CONCUSSION  OF  THE  SPINAL  CORD. 

{Commotio  Spinalis.) 

§  594.  Definition. — Concussion  of  the  spinal  cord  includes 
cases  in  which  traumatic  injuries  occasion  severe  functional 
disturbances  without  the  production  of  recognisable  changes. 

§  595.  Etiology. — The  most  usual  causes  of  spinal  con- 
cussion are  falls  upon  the  feet,  or  buttocks,  and  blows  over  the 


THE   SPINAL   CORD   AND   MEDULLA   OBLONGATA.  3G9 

back.  Another  common  cause  of  the  affection  is  the  shock  to 
the  whole  body,  occasioned  by  the  sudden  arrest  of  its  motion 
when  it  is  passing  at  a  rapid  rate  through  space,  such  as  occurs 
in  railway  collisions.  The  persons  who  sit  with  their  backs 
towards  the  direction  from  which  the  shock  comes  suffer  most 
from  spinal  concussion  in  railway  accidents. 

The  concussion  may  be  limited  to  a  portion  of  the  cord  when 
the  vertebral  column  has  been  struck,  but  in  cases  of  shock  to 
the  body  the  greater  portion  of  the  cord  or  the  whole  is  affected. 
Violent  mental  excitement  appears  to  produce  symptoms  of 
concussion  of  the  cord,  and  lightning  passing  through  the  body 
causes  a  general  shock  in  which  the  spinal  cord  participates. 

§  596.  Symptoms. — The  symptoms  vary  according  to  the 
nature  of  the  injury,  the  degree  of  individual  resistance,  and 
various  other  circumstances.  The  most  usual  symptoms  of  the 
affection  are  feebleness  of  the  extremities,  amounting  in  some 
cases  to  decided  paralysis,  parsesthesise  of  various  kinds,  pain 
in  the  neck,  loins,  or  along  the  spinal  column,  tenderness  on 
pressure  of  some  of  the  spinous  processes,  some  degree  of  cuta- 
neous hypersesthesia,  or  more  often  anaesthesia,  weakness  of  the 
bladder,  and  considerable  emotional  disturbance. 

§  597.  Varieties  of  Spinal  Concussion. — The  following 
varieties  may  be  distinguished  : — 

(1)  Severe  form  of  Shock,  giving  rise  to  Aggravated  Symptoms  at  once, 
and  Death  in  a  short  time. — The  patient  after  the  iujiiry  is  found  compa- 
ratively paralysed  in  all  his  extremities,  with  distinct  anaesthesia,  great 
prostration,  and  confusion  of  ideas  or  complete  loss  of  consciousness  and 
involuntary  evacuations.  The  pulse  is  small,  weak,  and  slow,  the  skin  is 
cool  and  pale  or  slightly  cyanotic,  and  there  may  be  respiratory  distur- 
bances amounting  sometimes  to  dyspnoea.  In  a  few  hours  or  days  death 
occurs  amid  general  prostration  and  paralysis  of  the  respiration. 

(2)  Slight  Shock  causing  Severe  Symptoms  at  the  moment  of  injury, 
biU  soon  ending  in  Recovery. — The  patient  is  found  immediately  after  the 
accident  more  or  less  paralysed  in  the  lower  extremities  and  sometimes  in 
the  upper  also,  and  complaining  of  severe  and  general  pain  in  the  body  or 
in  the  lower  half  of  it.  Some  degree  of  anaesthesia  is  usually  present,  but 
is  not  often  complete,  and  the  bladder  is  not  always  paralysed.  Soon 
after  the  accident  the  reflex  functions,  especially  the  tendinous  reflex 
actions,   may  be  found  exaggerated,  and  the  electrical  reaction  in   the 

Y 


370  TRAUMATIC  DISEASES  AND   AB^TORMALITIES   OF 

paretic  parts  may  be  increased  or  depressed.  Iraprovement  begins  in  a 
few  days.  The  patient  is  able  to  stand  and  walk,  at  first  slowly,  feebly, 
and  with  tremor  ;  the  pains  disappear,  and  recovery  is  complete  in  a  few 
weeks. 

(3)  Severe  Symptoms  at  first,  followed  by  Protracted  Illness  of  some 
years'  duration ;  Recovery  in  most  cases.  — The  patient  complains  of  motor 
weakness  soon  after  the  accident,  which  gradually  increases  until  the 
extremities  are  paralysed.  He  also  complains  of  pains  which  are  some 
times  more  or  less  diffased,  but  are  often  situated  in  the  back  of  the  neck, 
loins,  or  along  the  vertebral  column.  Various  parsssthesise  are  com- 
plained of,  but  ansesthesia  is  not  usually  well  marked.  Retention  of 
urine  sometimes  occurs.  There  may  be  vomiting  and  loss  of  consciousness 
at  first,  and  patients  often  manifest  a  high  degree  of  mental  irritability 
for  a  long  time.  The  extremities  are  cold  and  livid,  and  the  vertebral 
column  is  tender  on  pressure  and  often  excessively  sensitive.  Gradual 
improvement  now  occurs,  but  the  patient  complains  of  great  weakness  ; 
there  may  be  slight  atrophy  of  some  of  the  muscles,  and  complete  recovery 
may  not  take  place  for  several  years,  and  the  patient  may  remain  irritable 
and  sensitive  long  after  all  the  paralytic  symptoms  have  disappeared. 

(4)  Very  Slight  Symptoms  at  the  beginning,  but  after  a  longer  or  shorter 
time  a  Severe  Progressive  Spinal  Disease  develops ;  the  Result  is  Doubtful. 
These  cases  are  usually  caused  by  a  railway  collision,  and  the  symptoms 
are  generally  insignificant  immediately  after  the  injury.  The  patient 
has  a  sensation  of  having  been  severely  shaken,  suffers  from  momentary 
weakness  and  slight  confusion  of  mind,  but  soon  recovers,  picks  himself 
up,  and  walks  about.  On  the  next  day,  or  several  days,  weeks,  or  even 
months  later,  more  threatening  symptoms  set  in.  Pain  appears  in  the 
back  and  limbs,  and  gradually  increases  in  intensity;  the  patient  feels 
feeble,  suffers  from  mental  depression  and  sleeplessness,  with  a  strong 
tendency  to  emotional  weakness,  and  cannot  attend  to  his  business. 
He  also  often  complains  of  noises  in  the  ears,  and  there  may  be  slight 
deafness,  and  on  attempting  to  read,  the  letters  become  confused.  The 
subsequent  course  of  the  disease  varies  greatly  in  individual  cases,  but  the 
following  are  the  most  usual  phenomena  observed  :  The  gait  is  uncertain, 
straddUng,  stiff,  and  dragging,  indications  of  disturbed  co-ordination  are 
present,  and  the  legs  become  progressively  feebler.  There  is  stiffness  of 
the  back  and  of  the  general  attitude.  The  back  is  painful  when  moved, 
and  some  of  the  spinous  processes  are  tender  on  pressure.  Girdle 
sensations,  parsesthesise  of  all  sorts,  ansesthesiae  in  varying  degrees  and 
in  different  situations,  or  hypersesthesise,  may  be  present.  Weakness 
of  the  bladder  and  diminution  of  sexual  power  are  generally  present.  The 
expression  of  the  countenance  is  changed,  the  complexion  becomes  pale 
and  sallow,  and  the  general  nutrition  impaired.  Marked  atrophy  occurs 
in  individual  muscles  and  groups  of  muscles,  and  it  may  at  times  be  ex- 
tensively distributed.  Disturbances  of  circulation  manifest  themselves  in 
the  form  of  cold  extremities  and  bluish  complexion.     The  patient  is  irri- 


THE   SPINAL   CORD   AND   MEDULLA   OBLONGATA.  37 1 

table  and  timid,  suffers  from  a  feeling  of  constriction  of  the  head,  sleep- 
lessness, weakness  of  memory  and  intelligence,  impaired  power  of  work, 
and  in  fact  his  whole  character  has  undergone  change. 

The  symptoms  point  to  a  meningo-myelitis,  associated  with  more  or 
less  considerable  disturbances  of  the  cerebral  functions.  The  subsequent 
course  of  the  affection  varies.  Periods  of  apparent  improvement  and  com- 
parative health  alternate  with  those  of  downward  progress,  but  on  the 
whole  a  favourable  termination  is  seldom  witnessed.  Cases,  however, 
occur  in  which  the  disease  ceases  to  progress,  and  in  which  considerable 
improvement  may  take  place. 

§  598.  Morbid  Anatomy. — In  cases  which  have  terminated 
fatally  at  an  early  period  small  extravasations  of  blood  have  been 
found  in  the  cord  and  its  membranes,  but  it  is  probable  that 
these  are  of  secondary  importance  to  the  molecular  disturbance 
of  the  whole  substance  of  the  cord  produced  by  the  shock.  It 
is  probable  that  chronic  meningitis  and  myelitis  may  develop 
out  of  concussion,  and  then  the  usual  appearances  which  dis- 
tinguish these  affections  will  be  found  after  death. 

§  599.  Diagnosis. — Cases  of  concussion  in  which  severe  symp- 
toms develop  immediately  after  the  injury  may  be  mistaken 
for  crushing  or  contusion  of  the  cord,  hsematomyelia,  or  hsema- 
torrhachis.  The  course  of  concussion,  however,  is  much  more 
rapid  and  favourable.  It  may  be  inferred,  when  a  severe  para- 
plegia comes  to  a  favourable  ending  in  a  few  days  or  weeks 
without  bed-sores  or  other  grave  symptoms,  that  tbe  case  is  one 
of  concussion. 

The  initial  symptoms  are  more  severe  in  concussion  than  in 
ha^matorrhachis,  and  in  the  latter  affection  the  preponderant 
symptoms  are  those  of  pain  and  spasm,  and  the  paralysis  is 
slight,  while  in  the  former  the  opposite  conditions  obtain. 

Cases  of  concussion,  in  which  the  symptoms  are  slight  at  first 
and  gradually  increase  in  severity,  are  not  essentially  different 
from  myelitis  and  meningo-myelitis  with  a  slow  beginning,  and 
the  diagnosis  must  depend  in  great  measure  on  the  connection 
of  the  affection  with  an  injury. 

Crushing  of  the  cord  and  concussion  are  frequently  combined, 
so  that  it  is  almost  impossible  to  distinguish  between  the  symp- 
toms which  are  due  to  the  one  and  those  due  to  the  other, 


372  TEAUMATIC  DISEASES  AND  ABNORMALITIES  OF 

and  the  diagnosis  can  only  be  made  after  the  disappearance  of 
the  symptoms  of  concussion. 

§  600.  Prognosis. — In  the  severest  form  of  concussion  known 
as  shock  the  prognosis  is  always  grave,  but  the  slighter  cases  of 
the  kind  generally  recover.  Compared  with  the  severity  of  the 
symptoms  the  prognosis  is  good,  and  indeed  the  severe  initial 
symptoms  seem  to  be  the  very  cases  to  warrant  a  favourable 
prognosis  as  compared  with  those  the  development  of  which  is 
slow. 

Even  in  cases  where  symptoms  of  meningitis  or  myelitis 
appear,  the  prognosis  is  not  absolutely  bad,  but  when,  after  one 
or  two  years  of  rational  treatment,  no  further  progress  is  made, 
recovery  is  hardly  to  be  expected. 

§  601.  Treatment — The  treatment  must  vary  according  to 
the  form  assumed  by  the  affection. 

In  cases  with  severe  initial  symptoms  the  treatment  must 
be  first  directed  against  the  shock.  The  patient  must  be  placed 
in  the  recumbent  posture,  and  warmth  applied  to  the  body,  and 
full  doses  of  some  stimulant,  such  as  wine,  coffee,  tea,  hot 
spirit  and  water,  or  drugs  like  aromatic  spirit  of  ammonia 
ether,  musk,  and  camphor,  must  be  at  once  administered. 

Symptoms  of  reaction  must  be  treated  by  absolute  rest 
in  a  suitable  position.  If  the  patient  cannot  bear  lying  on  his 
face  or  side,  Erichsen  recommends  him  to  lie  on  his  back  on  a 
couch  tilted  at  its  foot.  The  usual  remedies  for  myelitis  must 
now  be  employed. 

(V.)  TUMOUKS  OF  THE  SPINAL  CORD  AND  MEDULLA 
OBLONGATA. 

§  602.  Tumours  are  rarely  found  in  the  substance  of  the 
spinal  cord,  but  are  more  frequent  in  the  medulla  oblongata. 

§  603.  Varieties  of  Tumours  found  in  the  Spinal  Cord 
and  Medulla  Oblongata. — The  following  are  the  more  usual 
tumours  found  in  the  substance  of  the  cord  and  in  the  medulla 
oblongata : — 

1.  Gliomata. — The  tumour  is  geuerally  of  a  rounded  or  more  or  less 


THE  SPINAL  CORD  AND  MEDULLA  OBLONGATA.  373 

elongated  shape,  but  at  other  times  it  may  extend  the  whole  length  of  the 
spinal  cord,  as  in  a  case  recorded  by  myself. 

2.  Myxo-Gliomata. — This  form  of  tumour  is  only  a  variety  of  Glioma. 

3.  Glio- Sarcomata,  Myxo-Sarcomata,  Sarcomata,  and  Carcinomata  are 
only  rarely  found  in  the  substance  of  the  cord  and  the  medulla  oblongata. 

4.  Fibromata  have  been  observed  in  the  medulla  oblongata,  either 
growing  from  the  ependyma  or  in  the  medullary  substance. 

5.  Solitary  Tubercle. — This  is  one  of  the  most  frequent  tumours  of  the 
spinal  cord.  It  may  appear  at  any  period  of  life,  but  is  relatively  more 
frequent  in  youth  than  in  old  age.  The  favourite  sites  of  solitary  tubercles 
are  the  cervical  and  lumbar  enlargements,  especially  the  latter.  They 
may  be  situated  either  in  the  grey  or  white  substance,  and  vary  in  size 
from  that  of  a  hemp-seed  to  a  hazel-nut.  Solitary  tubercle  may  attain 
to  the  size  of  a  walnut  in  the  medulla  oblongata. 

6.  Gummata  or  Syphilomata. — These  tumours  are  on  the  whole  rarely 
found  in  the  cord  and  medulla  oblongata. 

7.  The  cystic  dilatations,  which  have  been  called  hydromyelus  or 
syringomyelia,  may  be  reckoned  amongst  the  tumours  of  the  spinal  cord 
when  they  compress  the  nervous  substance  ;  they  are  often  associated 
with  new  growths,  such  as  gliomata,  myxo-gliomata,  and  myxo-sarcomata. 

§  604  Etiology. — The  causes  of  tumours  of  the  spinal  cord 
and  medulla  oblongata  are  very  obscure,  but  it  is  probable 
that  injuries,  such  as  blows  or  jars  of  the  spinal  column,  may 
act  as  exciting  causes. 

§  605.  Symptoms. 
(1)  Symptoms  of  Tumours  of  the  Spinal  Cord. — The  symp- 
toms caused  by  the  growth  of  a  tumour  within  the  substance 
of  the  cord  are  very  variable,  but  are  generally  the  same  as 
those  of  compression  myelitis.  They  are  paraplegia,  anses- 
thesia,  increased  reflex  action,  paralysis  of  the  bladder  and 
rectum,  muscular  atrophy,  and  bed-sores.  The  development  of 
paraplegia  may  be  preceded  by  shooting  pains  in  the  limbs, 
girdle  pains,  and  various  pareesthesise.  Indefinite  initial  symp- 
toms may  persist  for  a  long  time,  and  then  paralysis  develop 
suddenly,  occasioned  by  an  acute  attack  of  transverse  myelitis 
or  haemorrhage  into  the  substance  or  neighbourhood  of  the 
tumour.  The  development  of  paralysis  proceeds  at  other  times 
more  slowly.  One  limb,  probably  an  upper  extremity,  becomes 
first  affected,  the  other  extremities  becoming  gradually  impli- 
cated until  the  paraplegia  is  complete. 


374  TRAUMATIC  DISEASES  AND  ABNORMALITIES   OF 

In  slowly-growing  and  dense  tumours  the  nerve  fibres  appear 
to  be  thrust  aside  without  being  ruptured,  and  extensive  changes 
may  sometimes  be  found  after  death  in  the  cord  while  only 
very  slight  and  indefinite  symptoms  existed  during  life.  In  a 
few  cases  the  symptoms  are  caused  by  a  diffused  ascending 
myelitis,  while  in  occasional  instances  the  disappearance  of  the 
reflex  excitability  and  the  occurrence  of  extensive  muscular 
atrophy  indicate  that  the  grey  substance  has  been  destroyed 
by  a  secondary  descending  myelitis  or  by  a  descending  exten- 
sion of  the  new  growth. 

Various  other  symptoms  may  appear  in  the  course  of  the 
disease,  according  to  the  situation  of  the  tumour  and  the  direc- 
tion in  which  it  is  growing.  The  chief  groups  of  symptoms 
which  may  be  thus  caused  are  progressive  muscular  atrophy, 
ataxia,  and  spastic  paralysis. 

(2)  Symptoms  of  Tum^ours  of  the  Medulla  Oblongata. — 
Tumours  in  the  substance  of  the  medulla  oblongata  may 
remain  latent  for  a  long  time,  and  may  either  cause  no 
recognisable  symptoms  during  life,  or  not  until  a  few  hours  or 
days  before  death,  which  results  from  asphyxia. 

The  most  prominent  of  the  initial  symptoms  are  paroxysmal 
attacks  of  headache,  situated  in  the  occiput  or  nucha,  dizziness, 
violent  vomiting,  tinnitus  aurium,  hiccough,  and  occasionally 
epileptoid  attacks.  These  symptoms  persist  and  grow  worse, 
while  others  are  soon  superadded  to  them,  the  latter  being 
caused  by  compression  of  some  of  the  fibres  of  the  bulbar 
nerves  as  they  pass  through  the  medulla,  or  by  destruction  of 
portions  of  the  bulbar  nuclei.  The  most  usual  symptoms 
caused  by  compression  of  the  fibres  of  the  nerve  roots  are 
distortion  of  the  face,  unilateral  and  bilateral  paralysis  of  the 
tongue,  internal  squint,  disorders  of  articulation,  vocalisation, 
and  deglutition,  a  nasal  tone  of  voice,  and  disorders  of  circu- 
lation, and  respiration.  There  may  also  be  more  or  less  ex- 
tensive paralysis  of  the  extremities,  consisting  of  unilateral 
or  bilateral  paresis,  with  or  without  contractures.  Hemiplegia, 
alternating  with  paralysis  of  the  facial,  abducens,  or  hypo- 
glossal nerves,  forms  a  characteristic  symptom.  Reflex  action 
is  often  increased  in  the  extremities. 

Disorders    of    motor    co-ordination    have    sometimes    been 


THE   SPINAL   CORD   AND   MEDULLA   OBLONGATA.  375 

observed,  which  may  resemble  those  of  locomotor  ataxia,  but 
more  commonly  a  cerebellar  reel  (§  86),  probably  caused  by 
interference  with  the  peduncles  of  the  cerebellum. 

The  sensory  are  not  so  well  marked  as  the  motor  disturbances. 
They  generally  consist  of  pain,  and  parsesthesise  in  the  nucha, 
back,  and  extremities,  and  anaesthesia  may  occasionally  be  pre- 
sent in  the  trunk  and  extremities.  When  the  tumour  or  the 
inflammatory  action  which  surrounds  it  extends  into  the  pons, 
there  may  be  paralysis  of  the  masticatory  muscles,  hyperses- 
thesia,  neuralgic  pains,  and  subsequently  anaesthesia  of  one  or 
both  sides  of  the  face,  while  one  or  both  eyes  may  suffer  from 
neuroparalytic  ophthalmia.  Deafness  on  one  or  both  sides  may 
be  met  with,  and  double  optic  neuritis,  amblyopia  or  amaurosis 
are  almost  constant  accompaniments  of  the  presence  of  tumour 
within  the  cranial  cavity. 

Glycosuria  and  polyuria  may  be  present,  and  the  temperature 
of  the  body  is  generally  persistently  depressed. 

Psychical  disturbances,  such,  as  loss  of  intelligence  and 
memory,  have  occasionally  been  observed  at  an  early  period,  and 
are  almost  constantly  present  towards  the  termination  of  the 
disease.  These  symptoms  are  probably  caused  by  the  hydro- 
cephalus internus  which  almost  always  accompanies  tumours  of 
the  medulla.  The  eifusion  into  the  ventricles  may  be,  to  some 
extent,  caused  by  the  pressure  of  the  tumour  on  the  veins, 
especially  the  venae  galeni ;  but  probably  depends  rather  upon 
the  hindrance  offered  by  the  tumour  to  the  return  of  the  cerebro- 
spinal fluid  into  the  sub -arachnoid  space. 

As  the  disease  advances,  the  headache  and  paralytic  symp- 
toms grow  worse,  the  vomiting  and  hiccough  may  become 
incessant,  epileptic  attacks  occur  more  frequently,  coma  super- 
venes, and  the  patient  dies  from  asphyxia. 

§  606.  Localisation  of  the  Tumour  in  the  Cord  and  Medulla 

Oblongata. 
1.  Tumours  of  the  Spinal  Cord. — The  level  at  which  the  cord  is  affected 
can  generally  be  made  out  by  the  height  to  which  the  paralysis  extends, 
and  by  the  condition  of  the  various  cutaneous  and  deep  reflexes.  The 
extent  to  which  the  grey  substance  is  diseased,  either  by  the  invasion  of 
the  tumour  or  by  secondary  myelitis,  can  be  ascertained  by  the  muscular 
atrophy  and  other  trophic  affections  associated  with  the  paralysis  ;  while 


376  TRAUMATIC  DISEASES  AND  ABNORMALITIES   OF 

implication  of  the  posterior  or  lateral  columns  may  be  respectively 
recognised  by  the  presence  of  ataxia  or  spastic  paralysis. 

2.  Tumours  of  the  Medulla  Oblongata. — (a)  Tumours  in  the  anterior 
pyramids  of  the  medulla  produce  unilateral  or  bilateral  paralysis  of  the 
muscles  of  the  extremities  and  trunk,  accompanied  by  contractures  and 
increased  tendon  reflexes.  Paralysis  of  the  bladder  is  sometimes  super- 
added, but  sensibility  remains  unimpaired.  In  the  later  stages  of  the 
disease  the  symptoms  of  bulbar  paralysis  are  superadded. 

(6)  Tumours  on  the  floor  of  the  fourth  ventricle  may  cause  vomiting, 
hiccough,  glycosuria  and  polyuria,  slow  pulse,  and  respiratory  disorders. 
The  symptoms  which  indicate  paralysis  of  cranial  nerves  may  be  present, 
but  paralysis  of  the  extremities  if  present  at  all  is  a  late  symptom.  Sen- 
sory disorders  are  rare,  but  some  degree  of  ataxia  or  reeling  may  be  present. 

(c)  Tumours  of  the  restiform  body  may  give  rise  to  sensory  disorders  in 
the  extremities,  unilateral  anaesthesia  in  the  face,  auditory  troubles,  and 
ataxic  walk,  but  our  knowledge  of  the  symptoms  caused  by  these  tumours 
is  not  sufficiently  accurate. 

{d)  Tumours  of  the  formatio  reticularis  and  olivary  bodies  cause  no 
symptoms  by  which  their  presence  can  be  recognised,  except  those  com- 
mon to  intracranial  growths.  When,  however,  these  tumours  increase 
to  such  a  size  that  they  compress  the  bulbar  nuclei,  the  fibres  of  the  bulbar 
nerves  in  their  passage  through  the  medulla,  or  the  anterior  pyramids,  the 
grouping  of  the  symptoms  may  be  such  as  to  render  it  possible  to  make 
an  accurate  diagnosis  of  the  localisation  of  the  lesion.  The  following  case, 
for  the  notes  of  which  I  am  indebted  to  Mr.  Hodgson,  who  was  then  one 
of  the  House  Physicians  of  the  Royal  Infirmary,  well  exemplifies  the 
grouping  of  the  symptoms  which  may  take  place  from  a  tumour  com- 
mencing in  the  formatio  reticularis : — 

William  B ,  aet.  eight  years,  was  admitted  February  17,  1880,  into 

the  Royal  Infirmary,  under  the  care  of  Dr.  Ross.  He  is  a  well-nourished 
boy  for  his  years,  and  his  mental  faculties  do  not  appear  to  be  in  any 
way  impaired.  He  complains  of  headache,  and  the  occipital  region  is 
sensitive  to  touch.  Both  eyeballs  are  inverted,  the  external  recti  muscles 
being  completely  paralysed.  The  right  pupil  measures  5  and  the  left  3 
mm.,  but  both  contract  readily  to  light.  There  is  slight  facial  paralysis 
on  the  right  side  extending  to  the  eyelid  of  the  same  side,  which  cannot 
be  closed.  The  soft  palate  is  loose  and  pendulous,  and  the  uvula  occupies 
the  middle  line,  until  a  reflex  contraction  of  the  palatal  muscles  is  excited 
when  it  assumes  a  curved  form,  the  point  being  directed  to  the  right 
and  the  convexity  to  the  left.  There  are  no  sensory  disorders  of  the  face  or 
body,  no  loss  of  taste,  deafness,  paralysis  of  the  tongue,  or  recognisable 
paralysis  of  the  extremities.  The  reflex  contractility  of  the  right  facial 
muscles  is  diminished,  but  they  still  contract  to  a  faradic  medium  current. 
The  galvanic  contractility  is  also  somewhat  diminished,  but  there  are  no 
qualitative  changes.  When  the  child  stands  his  head  is  inclined  to 
the  left,  but  it  is  difficult  to  know  whether  this  attitude  is  due  to 


THE   SPINAL   CORD   AND   MEDULLA  OBLONGATA.  377 

paresis  of  the  right  sterno-cleido-mastoid  muscle,  or  to  a  voluntary 
effort  to  correct  the  false  images  caused  by  the  double  internal  squint. 
When  he  walks  his  gait  is  staggering,  and  he  manifests  a  constant 
tendency  to  fall  towards  the  right  side,  yet  there  is  no  paralysis  of  the 
right  lower  extremity.  The  cervical  glands  at  the  angles  of  the  jaws 
and  along  the  sterno-mastoid  muscles  on  both  sides  are  slightly  enlarged. 
The  heart  and  lungs  are  healthy.  The  urine  is  acid,  s.G.  1026,  contains  no 
albumen  or  sugar,  and  is  normal  in  quantity.  The  reflex  of  the  sole, 
and  the  cremasteric,  abdominal,  epigastric,  gluteal,  and  interscapular 
reflexes  are  normal. 

March  22.  When  the  patient  stands  he  reels  from  side  to  side,  and 
manifests  a  greater  tendency  to  fall  to  the  left  than  the  right,  and  the 
patellar-tendon  reflex  is  more  marked  in  the  left  than  right  leg.  There  is 
also  decided  paresis  of  both  the  lower  and  upper  extremity  on  the  left 
side.     Ophthalmoscopic  examination  reveals  double  optic  neuritis. 

April  9.  The  left  half  of  the  body  is  distinctly  paralysed,  with  mus- 
cular rigidity,  the  right  arm  is  feeble,  and  the  patient  cannot  stand. 
The  face  is  now  symmetrical,  and  there  is  decided  loss  of  expression, 
while  both  eyes  remain  open  during  sleep,  and  the  patient  cannot  close 
them.  The  power  of  articulation  is  interfered  with,  and  the  food  has 
to  be  placed  far  back  on  the  dorsum  of  the  tongue  in  order  to  secure 
deglutition.  The  masticatory  muscles  are  feeble,  the  jaw  hangs  loose, 
the  mouth  is  half  open,  and  saliva  dribbles  constantly  from  the  mouth. 
The  simple  movements  of  the  tongue  can  still  be  readily  effected. 

The  mental  faculties  are  becoming  blunted,  but  so  far  as  can  be  judged 
the  senses  of  taste  and  hearing  are  unimpaired,  while  even  the  sense  of 
sight  is  fairly  good.  Sensibility  to  pain  and  touch  are  impaired  on  both 
sides  of  the  face  and  in  the  limbs. 

May  11.  Since  last  report  the  paralytic  phenomena  have  become 
gradually  worse.  The  left  arm  and  leg  are  now  completely  paralysed, 
while  the  right  limbs  are  very  feeble.  There  is  double  facial  paralysis, 
masticatory  paralysis  with  contracture  of  the  muscles  so  that  the  jaws 
are  held  close  together,  and  increasing  difficulty  of  articulation  and 
deglutition.  The  right  conjunctiva  has  been  for  some  time  red,  and 
covered  by  tenacious  secretion,  and  the  cornea  is  now  becoming  cloudy. 
The  patient  has  had  an  attack  of  severe  vomiting  about  two  weeks  ago, 
but  it  has  not  recurred. 

May  20.  Since  last  report  the  symptoms  have  become  gradually  worse. 
All  the  limbs  are  paralysed,  the  right  cornea  is  ulcerated,  while  the  left 
conjunctiva  is  injected  and  covered  by  tenacious  secretion.  Inability  to 
swallow  was  manifested  this  morning,  and  he  died  in  the  afternoon  from 
arrest  of  respiration. 

At  the  autojysy  no  changes  worth  noting  are  observed  in  the  nervous 
system  with  the  exception  of  the  medulla  oblongata  and  pons.  On  the 
fourth  ventricle  being  exposed,  a  tumour  is  observed  to  project  from  its 
surface  on  a  level  with  the  striae  meduUares.     It  is  about  the  size  of  a 


378 


TRAUMATIC   DISEASES  AND   ABNORMALITIES  OF 


pigeon's  egg,  and  the  greater  portion  of  it  lies  to  the  right  of  the  median 
raph^,  while  it  projects  forwards  into  the  substance  of  the  medulla  and 
pons.  Two  tumours,  each  about  the  size  of  a  hazel-nut  and  occupying 
symmetrical  positions  on  each  side  of  the  middle  line,  are  observed  in 
the  upper  part  of  the  ventricle  immediately  under  the  valve  of  Vieussens. 
A  few  scattered  miliary  tubercles  are  found  in  the  apices  of  the  lungs. 
The  tumours  in  the  pons  were  tubercular. 

Dr.  Leech,  who  kindly  transferred  this  case  to  my  care,  told  me  that 
the  symptoms  began  by  internal  squint  of  the  right  eye,  and  staggering 
gait,  with  a  tendency  to  fall  to  the  right  side,  these  symptoms  being 
followed  by  right  facial  paralysis.  The  symptoms  were  so  definite  in  this 
case  that  an  accurate  diagnosis  could  readily  be  made.  The  headache, 
gradual  invasion  of  the  symptoms,  and  the  presence  of  double  optic  neuritis, 
showed  that  the  case  was  one  of  intracranial  tumour,  while  the  swelled 
glands  in  the  neck,  and  other  circumstances,  indicated  its  probable 
tubercular  nature.  The  succession  of  the  various  groups  of  bulbar 
symptoms  were  so  definite  that  there  could  be  no  possibility  of  mistaking 
the  localisation  of  the  main  focus  of  disease.  The  early  paralysis  of  the 
external  rectus  of  the  right  side  showed  that  the  primary  focus  began  on 
a  level  with  the  sixth  nerve,  and  to  the  right  of  the  median  raph§. 
Suppose,  then,  that  the  tumour  began  to  grow  in  the  formatio  reticularis 
on  the  right  side  {Fig.  185,  ar)  on  a  level  with  the  sixth  nerve  (rvi),  and 


RW/ 


Fig.  185.  Transverse  Section  of  the  Pons  on  a  Level  with  the  Points  of  Origin  of  the 
Sixth  and  Seventh  Nerves.     (See  Fig.  126,  p.  40.) 


THE   SPINAL   CORD   AND   MEDULLA   OBLONGATA.  379 

that  it  grew  equally  in  all  directions.  It  would  first  produce  paralysis  of  the 
right  external  rectus,  and  as  it  grew  forwards  it  would  press  on  the  trans- 
verse fibres  of  the  pons,  and  produce  reeling,  with  a  tendency  to  fall  to 
the  right,  or  the  symptoms  which  would  have  been  caused  by  disease  of  the 
middle  peduncle  of  the  cerebellum.  As  the  tumour  enlarged  to  the  right 
it  would  press  on  the  fibres  of  the  seventh  nerve  (Rvii),  and  cause 
paralysis  of  the  right  muscles  of  the  face,  having  the  characters  of  a 
peripheral  paralysis.  As  it  grew  towards  the  left  it  would  press  on  the 
left  sixth,  and  then  on  the  left  seventh  nerve,  causing  successively  in- 
ternal squint  of  the  left  eye  and  left  facial  peripheral  paralysis.  As  it 
grew  still  further  forwards  it  would  compress  the  fibres  of  the  pyramidal 
tract,  first  on  the  right  side,  causing  crossed  paralysis  of  the  left  ex- 
tremities, and  then  on  the  left  tract  (Fig.  185,  P,  p),  causing  paralysis 
of  the  extremities  on  the  right  side. 

Again  as  the  tumour  extended  downwards  it  would  compress  the  ninth, 
tenth,  twelfth,  and  probably  also  the  eleventh  nerves,  and  so  give  rise  to  the 
more  purely  bulbar  symptoms  present,  such  as  the  vomiting,  and  disorders 
of  articulation  and  deglutition.  As  it  extended  upwards  it  would  compress 
the  motor  and  to  some  extent  the  sensory  divisions  of  the  fifth  nerves, 
causing  the  masticatory  paralysis,  the  facial  sensory  disturbances,  and  the 
neuro-paralytic  ophthalmia.  Not  only  was  an  accurate  localisation  of  the 
lesion  capable  of  being  made  in  this  case,  but  we  were  even  able  to  anticipate 
to  a  large  extent  the  later  symptoms  which  supervened.  When  paralysis 
of  the  left  rectus  occurred,  we  were  able  to  foretell  that  it  would  soon  be 
followed  by  peripheral  paralysis  of  the  left  side  of  the  face.  It  was  also 
possible  to  anticipate  that  left  hemiplegia  would  supervene,  which 
would  end  in  general  paralysis  if  the  patient  survived  long  enough, 
and  that  the  upward  and  downward  extensions  of  the  tumour  would  give 
rise  to  motor  and  sensory  disturbances  in  the  region  of  the  fifth  on  the  one 
hand,  and  difficulties  of  articulation  and  deglutition  on  the  other. 

§  607.  Course,  Duration,  and  Terminations. — The  course 
of  intramedullary  tumour  is  usually  very  protracted,  and  the 
patient  may  live  for  many  months  after  complete  paraplegia 
is  established.  Intramedullary  tumours  are,  with  the  exception 
of  gummata,  uniformly  fatal.  Death  may  be  caused  by  cystitis, 
bed-sores,  and  their  consequences,  arrest  of  respiration  when  the 
myelitis  takes  an  ascending  course,  or  intercurrent  disease. 

The  course  of  tumours  of  the  medulla  oblongata  is  probably 
uniformly  fatal.  The  disease  may,  however,  extend  over  a 
period  of  years,  with  considerable  variations  in  the  intensity  of 
the  symptoms,  but,  as  a  rule,  it  proceeds  uninterruptedly  to  a 
fatal  termination. 


880  TRAUMATIC   DISEASES  OF  THE   SPINAL   COED. 

§  608.  Diagnosis. — It  is  not  always  possible  to  make  a  decided 
diagnosis;  but  the  presence  of  a  tumour  may  be  suspected 
when  the  intensity  of  the  paralytic  symptoms  fluctuate,  or 
when  symptoms  of  central  myelitis  or  hsematomyelia  supervene 
upon  those  of  a  long-continued  and  insidious  spiual  affection. 
Evidence  of  scrofula,  tuberculosis,  or  syphilis  may  greatly  aid 
the  diagnosis.  The  initial  symptoms  of  irritation  are  generally 
of  less  intensity  in  intramedullary  than  meningeal  tumour,  and 
the  former  is  more  apt  to  give  rise  to  an  ascending  myelitis 
than  the  latter. 

Tumour  of  the  medulla  oblongata  may  be  recognised  with 
some  certainty  when  the  general  symptoms  of  an  intracranial 
growth  are  accompanied  by  signs  of  local  irritation  or  paralysis 
of  some  of  the  bulbar  nerves,  and  when  in  addition  there  are  ob- 
stinate vomiting,  hiccough,  glycosuria,  or  polyuria.  When  ataxia 
or  reeling  is  a  prominent  symptom  of  tumour  of  the  medulla 
oblongata,  or  when  tumours  of  the  cerebellum  implicate  the 
medulla  secondarily,  it  may  be  impossible  to  distinguish 
tumours  in  the  two  regions.  If,  however,  the  patient  has  been 
under  observation  from  an  early  period  of  the  disease,  the 
mode  of  invasion  and  succession  of  the  symptoms  generally 
enables  the  diagnosis  to  be  accurately  made. 

In  progressive  bulbar  paralysis  the  regular  symptoms  of 
tumour  of  the  medulla  oblongata,  such  as  headache,  vomiting, 
hiccough,  disorders  of  hearing,  glycosuria,  amblyopia,  epilepti- 
form convulsions,  and  double  optic  neuritis,  are  never  present. 

It  may  be  impossible  to  distinguish  tumours  in  the  substance 
of  the  medulla  from  those  which  grow  in  the  membranes  or 
surrounding  bones,  but  signs  of  irritation  and  paralysis  in  the 
region  of  distribution  of  the  cranial  nerves  are  probably  less 
prominent  in  the  former  than  in  the  latter. 

§  609.  Prognosis. — Except  in  the  case  of  syphilitic  gummata, 
the  prognosis  is  absolutely  unfavourable. 

§  610.  Treatment. — It  is  only  when  syphilis  exists  that  treat- 
ment is  of  any  avail,  when  large  doses  of  iodide  of  potassium 
should  be  promptly  administered.  In  other  cases  the  treatment 
should  be  the  same  as  that  of  acute  and  chronic  myelitis. 


381 


CHAPTER    IX. 


DISEASES  OF   THE  MEMBRANES  OF  THE   SPINAL   CORD 
AND    MEDULLA   OBLONGATA. 

(I.)  VASCULAR   DISEASES    OF   THE   MEMBRANES. 


1.  Hypercemia  of  the  Spinal  Membranes. 

§  611.  Hypersemia  of  the  spinal  membranes  cannot  be  sepa- 
rated from  hypersemia  of  the  spinal  cord,  and  has  already  been 
sufficiently  considered. 

2.  Hcematorrhachis — Meningeal  Apoplexy. 

§  612.  Hsematorrhachis  implies  any  effusion  of  blood  in, 
about,  or  between  the  spinal  menmges. 

§  613.  Etiology. — The  disease  is  more  frequently  observed 
in  men  than  women,  but  very  little  is  known  with  respect  to 
the  predisposing  causes  of  the  affection. 

The  most  usual  exciting  causes  are  injuries  of  the  spinal 
column,  such  as  fractures  and  contusions.  Caries  of  the 
vertebrse  has  in  some  cases  led  to  injuries  of  the  vessels  of 
the  cord  and  to  hasmorrhage  from  them.  Excessive  bodily 
exertion,  the  violent  spasms  of  epilepsy,  eclampsia,  and  tetanus, 
the  sudden  suppression  of  accustomed  discharges,  and  all  the 
circumstances  which  induce  spinal  hypersemia  may  act  as  exciting 
causes  of  meningeal  apoplexy. 

Meningeal  hsemorrhage  may  occur  in  scorbutus,  purpura 
hsemorrhagica,  smallpox,  and  typhoid  fever  and  other  acute 
infectious  diseases.  Aneurisms  have  been  frequently  known  to 
rupture  into  the  vertebral  canal,  and  blood  effused  into  the 
brain  or  cerebral  membranes  may  sometimes  pass  down  into 
the  spinal  canal. 


382  DISEASES   OF  THE  MEMBRANES   OF   THE 

§  614.  Symptoms. — The  disease  begins  suddenly.  The  pa- 
tient is  attacked  with  violent  pains  and  falls  down,  but  generally 
"without  loss  of  consciousness.  The  development  of  the  disease  is 
occasionally  slower  and  more  gradual,  and  premonitory  symp- 
toms, such  as  lumbar  pains  and  headache,  may  then  be  present. 
The  severity  of  the  symptoms  may  increase  after  a  few  hours 
or  days. 

The  characteristic  symptoms  are  those  of  irritation  and  sub- 
sequent paralysis.  The  phenomena  of  irritation  consist  of  a 
violent  pain,  localised  at  a  spot  corresponding  to  the  seat  of  the 
haemorrhage  and  radiating  in  various  directions  along  the  dis- 
tribution of  the  nerves,  the  roots  of  which  are  first  implicated. 
Eccentric  sensations,  such  as  pain,  formication,  burning,  and 
tingling,  are  associated  with  the  local  pain,  and  hypereesthesia 
is  also  mentioned  as  being  occasionally  present. 

The  chief  symptoms  of  motor  irritation  are  spasmodic  jerking 
of  the  muscles  which  may  sometimes  increase  to  general  con- 
vulsions, trembling  of  the  extremities,  and  tonic  spasm  and 
contracture  of  various  groups  of  muscles.  During  this  stage  the 
vertebral  column  is  stiff  and  painful,  so  that  it  is  impossible  for 
the  patient  to  raise  himself  in  bed  or  to  assume  the  sitting 
posture. 

Paralytic  symptoms,  however,  soon  supervene  in  the  lower  ex- 
tremities, but  seldom  amount  to  complete  paraplegia.  There 
is  also  a  more  or  less  distinct  anaesthesia  of  the  lower  extremi- 
ties, associated  with  feelings  of  furriness  and  numbness,  as  well 
as  with  sensations  of  swelling  and  heaviness  in  the  limbs  and 
trunk.  The  distribution  of  the  symptoms  depends  upon  the 
seat  of  the  lesion. 

Reflex  excitability  is  said  to  be  depressed  in  some  cases,  but 
probably  this  only  occurs  in  the  regions  supplied  by  the  nerve 
roots  directly  affected.  Weakness  of  the  bladder  and  rectum  is 
rarely  mentioned,  but  may  be  present  in  severe  cases.  Fever  is 
absent  at  first,  but  may  occur  during  the  irritative  reaction 
which  sets  in  on  the  second  or  third  day. 

§  615.  Varieties  of  Meningeal  Hemorrhage. 

(1)  When  the  cervical  region  is  affected,  the  attack  begins  with  pain  in 
the  arms  and  shoulders,  stiffness  in  the  neck,  and  pain  in  the  occiput. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  883 

The  anaesthesia  and  paralysis  are  most  marked  in  the  upper  extremities, 
and  oculo-pupillary  symptoms,  difficulty  of  breathing,  and  a  retarded  and 
weak  pulse  may  be  present. 

(2)  When  the  dorsal  region  is  affected,  there  is  pain  in  the  back  and 
abdomen,  girdle-pain,  stiffness  in  the  dorsal  part  of  the  spine,  paralysis 
of  the  legs  and  abdominal  muscles,  while  the  reflex  excitability  is  retained 
in  the  lower  extremities. 

(3)  When  the  lumbar  region  is  affected,  there  are  pain  and  stiffness  in 
the  loins,  tearing  pains  in  the  lower  extremities,  perinaeum,  bladder,  and 
genitals,  well  marked  paralysis  of  the  lower  extremities  with  loss  of  reflex 
activity,  and  paralysis  of  bladder  and  rectum. 

§  616.  Course  and  Terminations — The  symptoms  remain 
stationary  for  some  time,  but  improvement  usually  sets  in 
sooner  or  later.  Tlie  symptoms  of  inflammatory  reaction  are 
seldom  prominent  or  soon  disappear.  The  disease  usually  runs 
a  favourable  course  when  it  is  uncomplicated,  and  in  a  few  weeks 
or  months  a  tolerably  good  recovery  may  be  anticipated.  Death, 
however,  is  not  a  rare  occurrence  when  the  haemorrhage  occurs 
at  a  high  level  so  as  to  affect  the  respiratory  centres.  If  the 
extravasation  be  large,  the  severity  of  the  compression  may  lead 
to  complete  paraplegia,  cystitis,  bed-sores,  and  their  usual  con- 
sequences. 

§  617.  Diagnosis. — The  diagnosis  must  be  founded  on  the 
sudden  occurrence  of  the  illness,  the  peculiar  combination  of 
phenomena  of  irritation  and  paralysis,  the  absence  of  severe 
cerebral  symptoms,  the  paraplegic  character  of  the  symptoms, 
the  speedy  improvement,  and  usually  favourable  termination. 
Meningeal  haemorrhage  may  be  distinguished  from  concussion 
of  the  spinal  cord  by  the  absence  of  spasm  and  other  symptoms 
of  irritation  in  the  latter.  From  spinal  apoplexy  the  meningeal 
affection  may  be  distinguished  by  the  severity  and  suddenness 
of  the  paralysis  and  the  high  degree  of  anaesthesia  in  the  former 

Both  meningitis  and  myelitis  develop  more  slowly  than 
meningeal  haemorrhage,  and  both  are  accompanied  by  fever. 
In  central  spinal  myelitis  marked  ansesthesia  is  never  wanting, 
and  paralysis  is  usually  complete  from  the  beginning. 

§  618.  Prognosis. — The  prognosis  is  always  doubtful;  but  if 
the  extent  of  the  haemorrhage  be  not  great,  and  if  it  be  not 


884  DISEASES   OF   THE   MEMBRANES   OF  THE 

caused  by  a  permanent  lesion,  such  as  the  growth  of  a  tunaour, 
improvement  and  complete  recovery  may  take  place.  When 
the  haemorrhage  is  considerable,  or  when  it  is  situated  in  the 
cervical  region,  or  if  the  symptoms  of  myelitis  supervene,  the 
prognosis  becomes  unfavourable.  When,  on  the  other  hand, 
the  hsemorrhage  is  small,  the  reaction  moderate,  and  the  patient 
young,  the  prognosis  is  favourable. 

§  619.  Treatment. — When  the  symptoms  of  meningeal 
hsemorrhage  have  occurred,  absolute  rest  in  the  horizontal 
posture,  with  the  patient  lying  on  his  side  or  face,  should 
be  maintained.  The  primary  object  is  to  prevent  the  bleeding 
from  extending,  the  most  usual  remedy  being  application  of  ice 
to  the  vertebral  column,  and  ergot  may  be  given  internally 
when  symptoms  of  inflammatory  reaction  set  in.  Leyden  recom- 
mends mercurial  inunction  and  repeated  small  doses  of  calomel. 
When  the  period  of  reaction  has  passed,  absorption  may  be 
promoted  by  the  external  and  internal  use  of  iodine,  and  the 
galvanic  current. 

o 

(11.)    INFLAMMATION   OF    THE    SPINAL    DURA    MATER. 

Pachymeningitis  Spinalis.  Peri-meningitis. 
§  620.  Pachymeningitis  may  be  subdivided  into  two  varieties : 
(1)  External  pachymeningitis,  when  the  morbid  products  are 
deposited  in  the  loose  cellular  tissue  between  the  dura  mater 
and  vertebrae;  and  (2)  Internal  pachymeningitis,  when  the 
inner  surface  of  the  dura  mater  is  attacked. 

(i.)  Pachymeningitis  Spinalis  Externa.    Peki -pachymeningitis. 

External  pachymeningitis  consists  of  inflammation  of  the 
outer  layers  of  the  dura  mater  and  the  cellular  tissue  sur- 
rounding it. 

§  621.  Etiology. — Various  diseases  in  and  about  the  verte- 
bral column,  such  as  vertebral  caries  and  bed-sores,  constitute 
the  most  frequent  causes  of  the  affection. 

§  622.  Symptoms. — Pain  in  the  back,  which  varies  in  its  seat 
and  extent  according  to  the  locality  of  the  lesion,  is  one  of 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  385 

the  most  constant  and  important  symptoms  of  the  affection. 
Rigidity  of  the  back,  which  renders  it  difficult  and  painful  for 
the  patient  to  sit  up,  spasm  of  various  groups  of  muscles,  eccen- 
tric pains  in  the  form  of  a  girdle  or  shooting  into  the  extremi- 
ties, formication  and  slight  hypersesthesia  of  the  skin,  are  the 
usual  symptoms  complained  of. 

After  a  time  symptoms  of  compression  of  the  cord  are  gradu- 
ally superadded.  Both  sensory  and  motor  paralysis  may  occur 
slowly  or  suddenly,  and  muscular  tension,  increased  reflex  action, 
especially  increased  tendon  reflex,  paralysis  of  the  sphincters,  and 
bed-sores  appear  after  a  time.  These  symptoms  are  caused 
partly  by  local  compression  of  the  cord  and  partly  by  myelitis 
and  secondary  degenerations. 

The  symptoms  may  develop  in  an  acute  or  chronic  form.  In 
the  acute  purulent  forms  the  prominent  symptoms  are  caused 
by  irritation,  while  in  the  chronic  fibrinous  form  the  symptoms 
of  compression  and  paralysis  of  the  cord  predominate. 

§  623.  Course. — When  pachymeningitis  externa  accompanies 
caries  of  the  vertebrse  the  disease  is  frequently  arrested  and  the 
paralytic  symptoms  disappear.  In  the  severer  cases  its  course 
may  vary,  but  is  usually  protracted,  and  only  after  the  lapse  of 
many  weeks  is  there  a  termination  in  recovery  or  death. 

§  624.  Morbid  Anatomy. — The  essential  nature  of  the 
affection  consists  of  an  inflammation  of  the  outer  layers  of  the 
dura  mater  and  surrounding  cellular  tissue,  with  exudation  of  a 
purulent,  plastic,  or  tuberculous  nature.  The  exudation  has 
been  found  as  much  as  half  an  inch  in  thickness.  The  inner 
surface  of  the  dura  is  also  thickened  and  opaque,  and  frequently 
covered  with  a  thin  fibrinous  deposit.  The  pia  mater  and 
arachnoid  do  not  often  participate  in  the  affection,  but  they 
have  at  times  been  found  adherent  to  the  dura,  opaque,  and 
infiltrated  with  pus.  The  morbid  changes  are  usually  limited 
to  a  small  portion  of  the  cord,  even  when  they  extend  over  the 
greater  part  of  the  dura  mater. 

The  cord  itself  is  more  or  less  compressed,  flattened,  ansemic, 
and  often  softened.  Red  softening  and  hypergemia  are  found 
in  the  neighbourhood  of  the  compressed  portion,  and  in  chronic 
z 


386  DISEASES  OF  THE  MEMBRANES  OF  THE 

cases  ascending  and  descending  secondary  degenerations  are 
observed.  The  nerve  roots  which  pass  out  at  the  seat  of  the 
pachymeningitis  are  compressed  and  atrophied,  or  inflamed  and 
soft.  The  primary  lesion  which  has  produced  the  pachymenin- 
gitis will  of  course  be  found  on  post-mortem  examination. 

§  625.  Diagnosis. — The  diagnosis  is  chiefly  founded  on  the 
slowly-increasing  symptoms  of  meningeal  irritation  and  of  com- 
pression of  the  cord.  Valuable  aid  to  diagnosis  may  be  obtained 
by  the  discovery  of  abscess  or  the  other  morbid  changes  near 
the  vertebral  column. 

§  626.  The  Prognosis  depends  upon  the  nature  of  the 
primary  lesion  which  has  caused  the  pachymeningitis. 

§  627.  Treatment. — The  first  aim  of  treatment  is  to  remove 
the  effects  of  the  original  lesion.  The  use  of  brine  baths,  iodide 
of  potassium  and  iodide  of  iron,  frictions  with  mercurial  oint- 
ment, and  various  other  remedies  have  been  employed,  and 
Charcot  recommends  the  use  of  the  cautery  for  obstinate  cases. 

(ii.)  Pachymeningitis  Interna  (Htpertrophica  et  H^mokehagica). 
§  628.  Definition. — Internal  pachymeningitis  is  an  inflam- 
mation chiefly  of  the  inner  surface  of  the  dura  mater,  with 
deposition  of  morbid  products  between  the  dura  mater  and 
arachnoid.  There  are  two  forms  of  the  disease :  (1)  Pachy- 
meningitis interna  hypertrophica,  consisting  of  thickening  of 
the  dura  mater;  and  (2)  pachymeningitis  interna  hsemorrhagica, 
or  hsematoma  of  the  spinal  dura  mater,  consisting  of  the  forma- 
tion of  successive  pseudo-membranous  layers,  between  which 
blood  is  effused. 

§  629.  Etiology. — The  causes  usually  assigned  to  the  hyper- 
trophic form  are  exposure  to  cold  and  damp,  and  excessive  use 
of  alcohol. 

The  hgemorrhagic  form  often  accompanies  hsematoma  of  the 
cerebral  dura  mater,  and  is  produced  by  the  same  causes.  It  is 
often  associated  with  dementia  paralytica  and  other  mental  dis- 
orders. It  appears  sometimes  to  result  from  alcoholic  excess, 
and  Leyden  has  described  a  traumatic  form. 


SPINAL   CORD  AND   MEDULLA   OBLONGATA,  387 

§  630.  Symptoms. — The  hyiJertrophic  foTTn  usually  occurs 
in  tbe  cervical  region,  and  has  been  described  by  Charcot 
under  the  name  of  pachym^ningite  cervicale  hypertrophique. 
During  the  first  stage  of  the  disease,  which  lasts  two  or  three 
months,  the  symptoms  of  sensory  irritation  predominate.  The 
most  usual  of  these  symptoms  are  neuralgiform  pains  in  the 
neck  and  head,  which  extend  to  the  shoulders  and  arms,  and 
a  painful  sensation  in  the  upper  part  of  the  chest,  as  if  the 
patient  were  bound  by  a  tight  cord.  The  muscles  of  the  neck 
are  in  a  state  of  spasmodic  rigidity,  the  patient  often  complains 
of  formication  and  numbness  of  the  upper  extremities,  and 
cutaneous  trophic  disturbances,  such  as  vesicular  and  herpetic 
eruptions,  may  make  their  appearance  on  the  upper  extremities. 

The  transition  to  the  second  stage  is  characterised  by  the 
gradual  development  of  paralysis  and  muscular  atrophy.  At 
first  there  is  simply  paresis  of  the  extremities,  which  after  a 
time  becomes  developed  into  a  more  or  less  complete  paralysis, 
with  flaccidity  of  the  affected  muscles.  In  the  upper  extremities 
the  paralysis  often  predominates  in  the  muscles  supplied  by  the 
ulnar  and  median  nerves,  while  those  supplied  by  the  musculo- 
spiral  nerve  are  comparatively  spared.  The  consequence  of 
this  mode  of  distribution  of  the  paralysis  is  that  the  hand  is 
maintained  in  the  position  of  exaggerated  extension,  the 
phalanges  are  flexed  on  the  metacarpal  bones  and  upon  one 
another,  so  that  the  fingers  are  held  like  claws,  and  the  thumb 

Fia.  186. 


Fig.  186  (After  Charcot).  Attitude  of  the  Hand  in  Pachymeningitis  Cervicali$ 
Hypertrophica,  when  the  disease  is  situated  on  a  level  with  the  lower  half  of  the 
cervical  enlargement  of  the  spinal  cord. 


388 


DISEASES   OF  THE  MEMBRANES  OF  THE 


is  extended  {Fig.  186),  This  position  of  the  hand  is  not,  how- 
ever, so  much  a  sign  of  the  disease  as  it  is  of  its  locality. 
When  this  deformity  is  present,  the  lesion  is  situated  in 
the  lower  half  of  the  cervical  enlargement  of  the  cord,  and 
the  distortion  indicates  that  the  roots  of  the  ulnar  and  me- 
dian nerves  stand  at  a  lower  level  in  the  cord  than  those  of 
the  musculo-spiral  nerve.  When  the  disease  is  situated  in  the 
upper  cervical  region  and  implicates  the  upper  portion  of  the 
cervical  enlargement,  the  resulting  deformity  differs  greatly  from 
that  just  described.  The  distortion  of  the  hand  present  under 
those  circumstances  is  shown  in  {Fig.  187),  taken  from  a 
photograph  of  a  remarkable  case  under  the  care  of  Dr.  Leech, 
The  arm  is  held  close  to  the  side,  the  forearm  is  extended  on 
the  arm  and  strongly  pronated,  the  hand  is  flexed  on  the 
forearm,  the  fingers  are  in  a  line  with  or  only  slightly  extended 
on  the  metacarpal  bones,  and  the  phalanges  are  extended  upon 
one  another,  while  the  thumb  is  flexed  into  the  palm  {Fig.  1 87). 

Fia.  187. 


Fig.  187.  Attitude  of  the  Hand  in  Pachymeninyitis  Cervicalis  Hypertrophica,  when 
the  lesion  is  situated  on  a  level  with  the  upper  half  of  the  cervical  enlargement. 


All  the  muscles  of  the  forearm  and  hand  were  no  doubt  more 
or  less  paralysed  in  this  case,  but  it  will  be  seen  that  the 
muscles  supplied  by  the  musculo-spiral  nerve  were  on  the 
whole  more  affected  than  those  supplied  by  the  ulnar  and 
median  nerves. 

The  paralysis  is  accompanied  by  marked  atrophy  and  loss  of 
the  faradic  contractility  of  the  affected  muscles.     After  a  time 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  389 

muscular  tension  and  contractures  appear  in  the  paralysed 
muscles,  and  circumscribed  areas  of  anaesthesia  may  be  ob- 
served in  the  skin  of  the  upper  extremities.  At  a  later  period 
the  lower  extremities  become  paralysed,  and  contractures  with 
increase  of  the  tendinous  reflexes  appear  after  a  time  in  the 
muscles,  similar  to  that  which  occurs  in  primary  lateral  sclerosis. 
The  muscles  of  the  lower  extremities  do  not  undergo  atrophy 
like  those  of  the  upper  extremities,  or  at  least  not  until  a  late 
period  of  the  disease.  In  severe  cases  complete  paraplegia,  with 
marked  ansesthesia,  paralysis  of  the  bladder,  and  bed-sores 
arise,  leading  to  a  fatal  termination. 

The  symptoms  are  at  first  due  to  compression  of  the  cord  by 
the  dura  mater  contracting  around  it  and  to  transverse  myelitis 
at  the  spot  compressed,  and  at  a  later  period  to  descending 
degeneration  of  the  pyramidal  tracts.  This  form  of  the  disease 
has  a  resemblance  to  progressive  muscular  atrophy,  amyotrophic 
lateral  sclerosis,  and  other  diseases  attended  by  atrophy.  The 
most  important  points  of  distinction  are  the  stage  of  pains,  the 
partial  ansesthesia,  and  the  paraplegia  without  atrophy. 

In  hmmorrhagiG  pachyTneningitis  interna  the  symptoms  are 
very  obscure,  and  usually  complicated  with  those  of  co-existing 
cerebral  disease.  They  point  to  a  slow  meningitis,  and  consist 
of  pains  in  the  loins  and  back,  tearing  pains  in  the  extremities, 
stiffness  of  the  vertebral  column,  increasing  muscular  weakness 
which  may  gradually  develop  into  complete  paraplegia,  contrac- 
tures, various  degrees  of  cutaneous  hypersesthesia  and  anses- 
thesia, and  weakness  of  the  bladder.  If  a  patient  with  these 
symptoms  be  at  the  same  time  suffering  from  cerebral  para- 
lysis and  chronic  alcoholism,  hsemorrhagic  pachymeningitis  may 
be  suspected. 

The  diagnosis  is  not  readily  made  in  this  form  of  the  affection. 

§  631.  Morbid  Anatomy. — In  the  hypertrophic  form  the 
dura  mater  is  much  thickened  and  consists  of  a  large  number  of 
concentric  layers  of  cicatricial  connective  tissue.  The  pia  mater 
and  arachnoid  are  also  thickened  and  adherent  to  the  dura 
mater.  The  thickened  membrane  may  compress  the  cord  on  one 
side,  or  from  behind  forwards,  but  usually  embraces  it  like  a 
ring.     The  compressed  portion  of  the  cord  is  pale  and  soft,  and 


390 


DISEASES  OF  THE  MEMBRANES  OF  THE 


generally  presents  all  the  characteristics  of  transverse  myelitis. 
The  nerve  roots  on  a  level  with  the  lesion  are  compressed,  and 
the  muscles  supplied  by  the  nerves  issuing  from  them  are  in  a 
condition  of  degenerative  atrophy. 


Fig.  188. 


Fig.  188  (From  Charcot  and  Joffroy).  Transverse  Section  of  the  Middle  of  the  Cer- 
vical Enlargement,  from  a  case  of  Sypertrophic  Cervical  Pachymeningitis. — A, 
Hypertrophied  dura  mater ;  B,  Roots  of  the  nerves  traversing  the  thickened 
membranes ;  C,  Pia  mater  adherent  to  the  dura  mater ;  D,  Lesion  of  chronic 
myelitis ;  E,  Cystic  formation  in  the  grey  substance. 

In  the  hcemorrhagic  form  a  portion  of  the  dura  mater  is 
covered  by  a  soft,  rusty-brown  exudation  composed  of  fibrine 
and  connective  tissue,  and  studded  with  numerous  hsemorrhagic 
extravasations.  The  exudation  contains  numerous  blood-crystals, 
pigment,  detritus  of  decomposed  blood,  and  is  only  slightly 
adherent  to  the  dura  mater  or  arachnoid,  so  that  it  is  readily 
stripped  oflf 

§  632.  Treatment — The  treatment  is  the  same  as  that  of 
meningitis  in  general. 

In  the  chronic  form  counter  irritation,  preparations  of  iodine, 
galvanism,  and  the  use  of  baths  or  the  cold  water  treatment 
deserve  a  trial. 


(III.)   INFLAMMATIONS   OF  THE   PIA  MATER  AND   SPINAL 
ARACHNOID. 

Leptomeningitis  Spinalis — Perimyelitis  and  Arachnitis. 
§  633.  Spinal  leptomeningitis  presents  many  varieties,  but 
for  practical  purposes  it  is  sufficient  to  subdivide  the  disease 
into  the  acute  and  chronic  forms. 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  391 

(i.)  Leptomeningitis  Spinalis  Acuta. 

The  acute  variety  begins  suddenly  with  violent  sensory  dis- 
turbances, attended  by  marked  fever. 

§  634.  Etiology. — The  predisposing  causes  of  the  affection 
are  a  scrofulous  or  tubercular  constitution,  insufficient  food, 
damp  dwellings,  and  sexual  and  other  excesses.  The  disease 
attacks  by  preference  children,  young  persons,  and  the  male  sex. 

The  most  important  of  the  exciting  causes  are  exposure  to 
cold,  wounds  and  injuries  of  the  vertebral  column,  and  exten- 
sion of  inflammation  from  neighbouring  structures.  Tubercular 
basal  meningitis  is  usually  accompanied  by  a  spinal  affection 
of  the  same  nature.  Spinal  meningitis  may  occur  along  with 
or  during  convalescence  from  pneumonia,  acute  articular  rheu- 
matism, and  other  febrile  and  infectious  diseases.  Epidemic 
cerebro-spinal  meningitis  will  be  subsequently  described. 

§  635.  Symptoms. — Acute  spinal  meningitis  is  generally 
complicated  by  a  simultaneous  affection  of  the  cerebral  pia 
mater,  so  that  it  is  not  always  easy  to  separate  the  purely 
spinal  from  the  cerebral  symptoms. 

The  disease  begins  suddenly,  but  the  outbreak  of  the  cha- 
racteristic phenomena  may  be  preceded  by  premonitory  symp- 
toms, such  as  general  heaviness  and  depression,  slight  chilliness, 
gastric  disturbances,  transitory  pains  in  the  head  and  back, 
restlessness,  and  sleeplessness. 

The  characteristic  symptoms  of  the  disease  are  ushered  in 
by  a  rigor  followed  by  pyrexia  of  irregular  type,  and  if  the  pia 
mater  of  the  brain  be  affected,  vomiting  and  severe  cerebral 
symptoms  are  also  present.  The  patient  now  complains  of  an 
intense,  deep-seated,  boring  pain  in  the  loins,  back,  or  nape  of 
the  neck,  corresponding  to  the  localisation  of  the  lesion.  The  pain 
is  increased  by  movements  of  the  vertebral  column  and  by  pres- 
sure on  the  spinous  processes.  The  pain  is  subject  to  remissions, 
followed  by  exacerbations  of  great  severity,  and  radiates  from 
the  vertebral  column  round  the  trunk,  shooting  in  all  directions 
through  the  extremities. 

The  muscles  of  the  vertebral  column  are  in  a  state  of  spas- 


392  DISEASES   OF  THE  MEMBRANES   OF   THE 

modic  rigidity.  When  the  inflammatory  process  is  limited,  the 
rigidity  may  be  limited  to  certain  portions  of  the  vertebral 
column  corresponding  to  the  situation  of  the  lesion,  but  the 
spasm  may  extend  over  the  whole  length  of  the  spine,  so  as  to 
resemble  a  tetanic  seizure. 

The  muscles  of  the  extremities  are  also  subject  to  painful 
tension  and  spasm.  The  limbs  are  then  rigid  and  immovable 
or  the  subjects  of  painful  twitchings. 

Cutaneous  and  muscular  hypersesthesia  is  often  present  in 
the  extremities  and  trunk  in  places  corresponding  to  the  areas 
of  distribution  of  the  nerves  whose  posterior  roots  are  involved 
in  the  inflammation.  Reflex  activity  is  at  first  increased  and 
subsequently  diminished. 

Functional  disturbances  of  the  bladder  and  rectum  appear  at 
an  early  period  of  the  disease,  probably  owing  to  a  spasm  of  the 
sphincters.  When  the  cervical  part  of  the  cord  is  involved  in 
the  inflammation  the  muscles  of  respiration  become  rigid  and 
painful,  producing  difficulty  of  breathing,  which  may  increase 
to  such  an  extent  as  to  cause  asphyxia. 

When  the  cerebral  pia  mater  is  implicated  the  patient  may 
suffer  from  vertigo,  violent  headache,  delirium,  unconsciousness, 
and  coma.  These  may  occur  at  an  early  or  late  period  of  the 
disease,  and  usually  indicate  a  fatal  termination. 

As  the  disease  progresses  symptoms  of  sensory  and  motor 
paralysis  supervene,  although  those  indicative  of  irritation  may 
for  a  time  be  variously  combined  with  them.  Cutaneous 
sensibility  becomes  diminished  and  complete  anaesthesia  may  be 
established,  while  the  extremities  manifest  various  degrees  of 
motor  weakness  up  to  complete  paralysis.  When  the  lesion  is 
situated  high  up,  paralysis  of  the  respiratory  mechanism  may 
lead  to  a  fatal  termination,  and  the  Cheyne-Stokes  respiration 
has  been  repeatedly  observed  towards  the  fatal  termination. 
The  pupils  may  be  contracted,  dilated,  and  unequal.  In  fatal 
cases  deep  coma  supervenes,  accompanied  by  a  rapid  elevation 
of  temperature. 

At  other  times  deceitful  signs  of  temporary  improvement 
appear,  but  paralysis  and  bed-sores  supervene,  and  death  follows 
after  long  suffering.  Sometimes,  however,  there  is  real  improve- 
ment, and  slight  cases  may  speedily  recover,  but  in  most  instances 


SPINAL  CORD  AND  MEDULLA   OBLONGATA.  398 

convalescence  is  slow  and  the  symptoms  of  sensory  and  motor 
irritation  only  disappear  after  a  long  period. 

Incurable  defects  are  often  left  behind,  such  as  anaesthesia 
of  variable  degree  and  extent,  and  paralysis  of  individual 
muscles,  groups  of  muscles,  or  of  entire  extremities.  The 
muscular  paralysis  may  be  associated  with  atrophy  and  con- 
tractures. The  symptoms  which  indicate  sclerosis  of  single 
columns  of  the  cord,  such  as  ataxia  and  spastic  paralysis,  may 
sometimes  become  permanently  established. 

If  the  inflammation  extend  to  the  medulla  oblongata  or  to  the 
base  of  the  cranium,  the  characteristic  symptoms,  vomiting,  head- 
ache, delirium,  and  paralysis  of  the  ocular  muscles,  supervene. 

§  636.  Course,  Duration,  and  Termination. — In  cerebro- 
spinal meningitis  death  occurs  early,  occasionally  within  a  few 
hours,  but  more  usually  it  is  postponed  for  a  few  days.  In  less 
violent  cases  the  duration  may  be  two  or  three  weeks,  and  the 
severity  of  the  symptoms  fluctuates  greatly. 

In  other  cases  the  acute  symptoms  subside  and  the  disease 
assumes  a  chronic  form  which  is  usually  associated  with  mye- 
litis. Cystitis  and  bed-sores  supervene,  and  the  patient  dies 
from  exhaustion. 

In  mild  cases  the  threatening  symptoms  may  disappear 
rapidly  and  the  patient  speedily  recover.  But  convalescence  is 
as  a  rule  protracted  even  when  the  patient  ultimately  makes 
a  complete  recovery,  but  in  a  large  number  of  cases  a  certain 
amount  of  paralysis  and  anaesthesia  remains. 

§  637.  Morhid  Anatomy. — The  morbid  changes  found  in 
acute  spinal  meningitis  may  be  subdivided  into  three  groups, 
according  to  the  period  of  the  disease  : — (1)  A  stage  of  hyper- 
semia  and  commencing  exudation;  (2)  a  stage  of  serous,  purulent, 
or  fibrinous  exudation  ;  (3)  a  stage  in  which  chronic  changes  are 
established. 

(1)  In  the  first  stage  the  pia  mater  is  congested,  of  a  rosy 
or  a  dark  red  tint,  and  dotted  with  hsemorrhagic  extravasations. 
The  tissue  is  swollen,  infiltrated  with  serum,  and  the  cerebro- 
spinal fluid  is  slightly  turbid.  The  arachnoid  is  also  congested, 
and  the  hypersemia  extends  to  the  cord  and  to  the  dura  mater. 


394  DISEASES   OF   THE  MEMBRANES  OF  THE 

(2)  In  the  second  stage  the  spinal  fluid  becomes  more  and 
more  turbid,  and  fibrinous  flakes  and  plates  are  found  in  the 
subarachnoid  tissue  or  adhering  to  the  surface  of  the  dura  mater. 
The  pia  mater  becomes  more  and  more  opaque,  and  the  sub- 
arachnoid tissues  are  transformed  into  a  gelatinous  mass.  The 
exudation  becomes  more  and  more  purulent,  and  at  last  the 
whole  pia  mater  and  subarachnoid  tissues  are  infiltrated  with 
pus.  The  spinal  fluid  assumes  a  sero-purulent  appearance  and 
contains  numerous  flakes  of  fibrin e. 

Small  miliary  nodules  may  be  found  in  some  cases  distributed 
along  the  course  of  the  vessels  of  the  pia  mater,  constituting 
tubercular  spinal  meningitis. 

The  distribution  of  the  exudation  varies  greatly.  It  usually 
covers  the  greater  part  or  the  whole  of  the  cord,  but  the  posterior 
surface  is  affected  in  a  greater  extent  than  the  anterior,  and 
the  changes  are  sometimes  limited  to  a  small  portion  of  the 
cord.  The  exudation  not  unfrequently  extends  from  the  spinal 
canal  into  the  brain,  and  the  arachnoid  is  always  involved  in 
the  inflammatory  action.  It  is  thickened,  opaque,  infiltrated 
with  serum  or  pus,  and  often  abounds  with  grey  miliary  tubercles, 
while  the  subarachnoid  tissue  is  similarly  affected. 

The  dura  mater  is  often  hypersemic,  opaque,  and  covered  with 
thin  fibro-purulent  exudation.  The  nerve  roots  are  almost 
always  involved,  they  are  enveloped  in  thick  masses  of  exuda- 
tion, and  are  often  swollen  and  softened.  The  cord  itself  is  pale 
and  oedematous,  or  congested,  and  is  usually  softened  either  at 
limited  spots  or  diffusely. 

(3)  In  the  third  stage  chronic  changes  supervene  and  become 
permanent,  the  most  common  of  these  being  opacity  and 
thickening  of  the  spinal  membranes,  adhesions,  accumulations 
of  fluid  in  the  arachnoidal  space  (hydrorrhachis),  and  sclerosis 
and  atrophy,  either  diffused  through  the  cord  or  affecting 
isolated  portions  or  systems.  In  cases  where  absorption  has 
taken  place,  there  is,  of  course,  no  third  stage. 

§  638.  Morbid  Physiology. — The  pains  in  the  back,  eccen- 
tric pains  in  the  extremities,  hypersesthesia,  and  muscular  rigidity 
and  twitchings  are  caused  by  irritation  of  the  posterior  and 
anterior  roots  of  the  nerves.     The  sensory  and  motor  paralysis 


SPINAL   CORD  AND   MEDULLA  OBLONGATA.  395 

which  characterises  the  second  stage  of  the  disease  is  caused 
by  the  compression  of  the  nervous  tissues  occasioned  by  the 
exudation.  Implication  of  the  anterior  roots  and  anterior  grey 
horns  explains  the  muscular  atrophy  which  is  sometimes 
observed,  while  affection  of  the  posterior  grey  horns  in  the 
lumbar  region  accounts  for  the  paralysis  of  the  bladder  and 
rectum, cystitis,  and  bed-sores  which  are  sometimes  present,  while 
extension  of  the  morbid  process  to  the  upper  part  of  the  cervical 
region  causes  the  disturbances  of  respiration  which  occur. 

§  639.  Diagnosis. — 'The  general  evidences  of  the  disease 
are  fever,  pain  and  rigidity  of  the  back,  stiffness  of  the  neck, 
muscular  spasms,  cutaneous  hyperaesthesia  and  parsesthesia, 
pains  in  and  paralysis  of  the  limbs,  retention  of  urine,  consti- 
pation, and  dyspnoea. 

When  the  membranes  of  the  brain  are  implicated,  the  cerebral 
symptoms  will  of  course  constitute  the  most  prominent  feature 
of  the  disease. 

It  is  not  always  possible  to  distinguish  acute  spinal  meningitis 
from  acute  myelitis,  inasmuch  as  the  two  affections  are  often 
combined.  Stiffness  in  the  back  and  neck,  eccentric  pains  in 
the  limbs,  and  hypersesthesise  are  characteristic  of  acute  spinal 
meningitis ;  while  sensory  and  motor  paralysis  predominate  in 
myelitis. 

In  tetanus  cerebral  symptoms  are  always  absent,  there  is 
no  hypersesthesia  of  the  skin,  and  reflex  excitability  is  very 
greatly  exaggerated.  The  presence  of  the  risus  sardonicus  and 
the  early  occurrence  and  severity  of  the  tetanic  spasm  in 
tetanus  render  the  diagnosis  between  it  and  spinal  meningitis 
as  a  rule  easy. 

The  diagnosis  of  the  tubercular  form  of  the  disease  must  rest 
chiefly  on  general  considerations,  such  as  the  evidence  of  scrofula 
or  tuberculosis  of  other  organs.  It  is  probably  always  associated 
with  tubercular  basilar  meningitis ;  so  that  the  presence  of  the 
cerebral  symptoms  characteristic  of  that  affection  may  be  of 
use  in  clearing  up  the  diagnosis  of  the  spinal  disease. 

§  640.  Prognosis. — The  prognosis  varies  greatly  in  different 
cases.     Hyperacute  and  tubercular  meningitis,  and  that  caused 


396  DISEASES   OF  THE  MEMBRANES   OF  THE 

by  deep  bed-sores,  are  always  fatal.  The  prognosis  is  more 
favourable  in  rheumatic  and  traumatic  cases.  The  prognosis 
is  unfavourably  influenced  by  the  following  circumstances  :  very 
young  or  advanced  age,  implication  of  the  cervical  portion  of 
the  cord,  early  symptoms  of  paralysis,  signs  of  exhaustion,  high 
fever,  progressive  rise  of  temperature  and  frequency  of  pulse, 
great  diSiculty  of  breathing,  and  severe  cerebral  symptoms. 

§  641.  Treatment. — In  the  early  stage  of  the  affection  energetic 
antiphlogistic  treatment  must  be  adopted.  The  main  remedies 
of  this  class  are  blood-letting  and  the  application  of  cold.  Local 
blood-letting  will  generally  suffice,  and  cold  must  be  applied 
sedulously  by  means  of  Chapman's  ice-bags.  A  smart  purgative, 
such  as  the  compound  jalap  powder  or  the  aperient  saline  waters, 
may  also  be  administered. 

When  the  temperature  has  fallen  slightly  blisters  may  be 
applied  along  the  spine,  and  in  the  milder  cases  weaker  counter- 
irritants  may  be  adopted.  Mercury  is  very  useful  in  the  treat- 
ment, the  inunction  being  the  best  method  of  application.  From 
fifteen  grains  to  a  drachm  of  the  ointment  should  be  rubbed 
daily  into  the  back  and  extremities.  The  patient  should  be 
placed  in  a  quiet,  airy,  moderately-warmed  room,  and  kept  lying 
in  the  recumbent  posture  on  his  side  and  face,  and  should  be 
prevented  from  using  any  exertion.  Nourishment  should  be 
fluid,  easily  digestible  at  first,  but  care  must  be  taken  to  allow 
a  more  generous  diet  at  an  early  period  of  the  disease. 

Various  symptoms  require  to  be  treated  during  the  course  of 
the  aflection.  Sedatives  are  required  in  order  to  relieve  pain, 
sleeplessness,  and  hypersesthesia,  and  for  this  purpose  large 
doses  of  opium  and  subcutaneous  injections  of  morphia  are  best. 
Warm  baths  afford  great  relief,  and  moist  packing  of  the  whole 
body  often  soothes  and  induces  sleep. 

When  the  affection  has  assumed  the  chronic  form,  large  doses 
of  iodide  of  potassium  should  be  administered.  The  sequelae, 
such  as  paralysis,  atrophy,  ansesthesia,  and  weakness  of  the 
bladder,  must  be  treated  with  baths  and  electricity. 

(ii.)  Leptomeningitis  Spinalis  Chronica. 
§  G42.  Etiology. — The  disease  frequently  develops  from  the 


SPINAL   COED  AND  MEDULLA  OBLONGATA.  897 

acute  form  and  then  has  the  same  causes.  The  acute  form  is 
more  apt  to  degenerate  into  the  chronic  variety  in  debilitated 
and  badly-nourished  subjects,  or  in  those  who  are  addicted 
to  alcoholic  and  other  excesses. 

§  643.  Symptoms. — The  symptoms  are,  on  the  whole,  the 
same  as  those  of  the  acute  variety,  but  they  develop  more 
gradually,  and  are  slower  in  their  progress.  When  the  disease 
develops  from  the  acute  form  the  violent  symptoms  disappear, 
but  the  pain,  stiffness,  abnormal  sensations,  and  paralysis 
remain  for  a  longer  time,  and  the  disease  passes  on  to  become 
chronic. 

In  the  majority  of  cases  the  disease  begins  in  an  insidious 
manner,  the  commencement  being  marked  by  abnormal  sensa- 
tions in  the  lower  extremities,  gradually  increasing  pain  and 
stiffness  of  the  back  and  neck.  The  pain  in  the  back  is  described 
as  a  feeling  of  drawing  and  pressure  in  the  loins,  and  is  aggravated 
by  movements  of  the  vertebral  column,  though  not  increased  by 
pressure  on  the  spinous  processes. 

A  girdle  sensation,  as  well  as  shooting  and  boring  pains,  is 
felt  in  the  trunk,  on  a  level  with  the  morbid  lesion.  The  patient 
complains  of  tingling,  formication,  and  a  feeling  of  coldness 
in  the  limbs,  which  feel  weak  and  heavy.  These  abnormal 
sensations  may  be  accompanied  by  tearing  or  shooting  pains, 
either  limited  to  the  region  of  some  nerve  trunk,  or  changing 
from  one  place  to  another. 

The  eccentric  symptoms  are  limited  to  the  region  of  distri- 
bution of  the  nerves  whose  roots  originate  in  the  part  chiefly 
affected,  and  they  are  more  marked  as  a  rule  in  the  lower 
extremities,  although  the  upper  are  not  unfrequently  affected. 

Symptoms  of  motor  irritation  are  of  subordinate  importance 
ia  chronic  meningitis,  although  some  are  almost  always  present. 
A  certain  degree  of  stiffness  of  the  back  and  neck  and  involun- 
tary drawing  up  or  extension  of  the  limbs  are  rarely  absent. 

The  heaviness  and  weakness  of  the  limbs  gradually  increase, 
but  the  paraplegia  in  spinal  meningitis  is  seldom  complete  and 
fluctuates  in  its  intensity  from  day  to  day.  If  there  be  a  con- 
siderable effusion  of  spinal  fluid  the  paralysis  increases  when 
the  patient  stands;  but  at  other  times  the  paralysis  increases 


398  DISEASES  OF   THE  MEMBRANES   OF  THE 

when  the  patient  is  lying  on  his  back,  and  then  it  is  probable 
that  the  cord  is  liable  to  become  passively  congested. 

Hypersesthesia  is  a  frequent  symptom,  but  anaesthesia  is  rare. 
There  is  usually  only  slight  blunting  of  the  cutaneous  sensi- 
bility, limited  to  the  feet  and  lower  part  of  the  legs. 

In  severe  cases  the  muscles  may  undergo  atrophy  with  loss  of 
electric  excitability.  Ansesthesia  is  developed,  the  reflex  actions 
are  abolished,  bed-sores  and  cystitis  appear,  and  the  patient 
dies  from  pyaemia  and  marasmus. 

§  644.  Course,  Duration,  and  Results. — The  disease  is  always 
slow,  and  extends  over  a  period  of  months  or  years.  Some  cases 
recover,  but  the  return  to  health  is  slow,  and  often  interrupted 
by  relapses.  The  sensory  disturbances  are  the  first  to  disappear, 
the  motor  persisting  longer.  In  many  cases  recovery  is  only 
partial,  and  paralysis  of  some  muscles  or  extremities,  with  or 
without  atrophy,  circumscribed  ansesthesia,  weakness  of  the 
bladder,  and  other  symptoms  remain  permanently.  In  the  great 
majority  of  cases  chronic  meningitis  ends  after  a  time  fatally. 
The  symptoms  which  precede  and  cause  death  are  usually  para- 
plegia, paralysis  of  the  bladder,  cystitis,  bed-sores,  and  marasmus. 
In  other  cases  the  morbid  process  extends  to  the  cervical  region, 
giving  rise  to  difficulty  of  breathing.  At  other  times  death  is 
brought  about  by  an  acute  attack  of  purulent  meningitis  super- 
vening on  the  chronic  form.  Death  may  also  be  caused  by 
many  other  complications  and  accidents. 

§  G45.  Morbid  Anatomy. — The  pia  mater  and  arachnoid  in 
chronic  spinal  leptomeningitis  are  congested,  thickened,  opaque, 
often  pigmented,  and  closely  adherent  to  the  dura  mater  on  the 
one  side  and  the  cord  on  the  other.  The  spinal  fluid  is  usually 
in  excess ;  it  is  generally  turbid,  tinged  with  blood,  or  mixed 
with  an  abundant  fibrinous  exudation.  Numerous  thin  and 
small  calcareous  plates  may  be  observed  on  the  arachnoid, 
especially  in  the  lumbar  region.  The  cord  is  usually  implicated 
in  the  morbid  changes.  Transverse  myelitis,  or  cortical,  syste- 
matic, or  disseminated  sclerosis  may  be  observed. 

§  646.   Diagnosis, — The  diagnosis  of  chronic  spinal  lepto- 


SPINAL   CORD   AND  MEDULLA   OBLONGATA,  399 

meningitis  presents  no  difficulty  when  the  disease  is  fully 
developed  and  uncomplicated,  but  is  difficult  during  the  first 
obscure  symptoms  of  the  affection,  and  when  it  is  complicated 
with  chronic  myelitis. 

Pain  and  stiffness  in  the  back,  eccentric  pains  in  the  extre- 
mities, girdle  pains,  and  other  symptoms  caused  by  irritation 
of  the  roots  of  the  nerves,  a  slight  degree  of  paralysis  with 
fluctuations  in  its  intensity,  especially  when  the  last  varies 
according  as  the  patient  is  in  the  prone  or  erect  posture,  hyper- 
sesthesia  or  a  slight  degree  of  anesthesia,  normal  or  absent 
tendon  reflexes,  and  painful  muscular  jerkings  point  strongly 
to  spinal  meningitis. 

When  severe  paralysis  and  anaesthesia  are  present,  the  pains 
slight,  and  the  tendinous  reflexes  exaggerated,  the  presence  of 
myelitis  may  be  inferred. 

Spinal  meningitis  may  be  readily  distinguished  from  loco- 
motor ataxy,  but  it  must  be  remembered  that  the  two  diseases 
are  often  combined. 

§  647.  Prognosis. — The  prognosis  is  always  grave,  although 
many  apparently  hopeless  cases  have  been  known  to  recover ; 
as  a  rule,  some  permanent  damage  to  the  cord  is  generally  left 
behind. 

§  64)8.  Treatment. — The  acute  form  should  always  be  sub- 
jected to  energetic  treatment,  with  the  view  of  avoiding  the 
establishment  of  the  chronic  variety.  Active  antiphlogistic 
treatment  does  no  good  in  the  chronic  form  of  the  disease. 

Counter-irritation  along  the  vertebral  column  is  one  of  our 
best  means  of  treatment.  Repeated  large  blisters  to  the  back 
are  the  most  effectual  of  this  class,  although  the  milder  counter- 
irritants  may  be  sufficient  in  some  cases. 

Iodide  of  potassium  in  moderate  doses  is  the  only  reliable 
internal  medicine.  Mercury  should  not  be  administered  unless 
the  presence  of  syphilis  be  suspected.  Ergot  and  belladonna 
are  of  no  use.  The  patient  should  be  kept  warm,  and  warm 
baths  of  all  sorts  are  efficacious. 


400  DISEASES  OF  THE  MEMBRANES  OF  THE 

(IV.)    TUMOUES   OF   THE    SPINAL    MEMBRANE. 

§  649.  The  tumours  which  are  found  within  the  spinal  canal 
usually  develop  from  the  spinal  membranes.  The  majority  of 
them  spring  from  the  dura  mater,  but  some  originate  from  the 
arachnoid  and  pia  mater,  and  remain  limited  to  these  mem- 
branes. Morbid  growths  may  also  arise  from  the  neighbouring 
structures  and  extend  towards  the  canal  so  as  to  involve  the 
membranes  secondarily. 

§  650.  Etiology. —  The  causes  of  meningeal  tumours  are 
obscure.  Many  cases  have  been  observed  where  the  first  symp- 
toms occur  after  a  fall  or  blow  on  the  back  or  spine  ;  in  many 
cases  the  commencement  of  the  disease  dates  from  childhood. 
Disease  of  the  vertebrae,  the  tubercular  and  scrofulous  diathesis, 
syphilis,  and  probably  an  inherited  tendency  to  the  formation 
of  carcinomatous  and  other  growths  are  the  main  predisposing 
causes. 

§  651.  Symptoms. — The  symptoms  may  be  divided  into  two 
groups — (1)  those  caused  by  local  irritation  and  compression  of 
the  nerve-roots  and  membranes  first  involved  in  the  tumour  ; 
and  (2)  those  caused  by  irritation  and  compression  of  the  cord 
itself,  and  by  consecutive  myelitis. 

The  symptoms  of  the  first  group  may  precede  those  of  the 
second  by  many  years.  They  are  very  variable,  as  might  be 
expected,  when  it  is  considered  that  they  must  largely  depend 
upon  the  locality  of  the  tumour,  and  the  direction  and  rate  of 
its  growth. 

Violent  Pains  of  a  lancinating,  tearing,  and  boring  character 
are  complained  of,  and  these  may  remain  confined  to  a  single 
point,  or  attack  a  nerve  trunk.  They  either  surround  the 
trunk  like  a  girdle  at  various  levels,  or  invade  the  upper  or 
lower  extremities  of  one  or  both  sides.  They  may  also  extend 
gradually  or  suddenly  into  neighbouring  nerve  districts.  They 
are  often  increased  by  movement  of  the  spinal  column,  and, 
like  all  neuralgic  pains,  are  made  worse  by  sudden  changes  of 
weather. 

FarcesthesicB,  such  as  tingling,  formication,  numbness,  either 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  401 

in  the  form  of  a  girdle  or  limited  to  certain  regions  of  the 
extremities,  are  observed. 

Twitchings  and  Spasms  of  individual  muscles  may  appear 
when  the  motor  roots  are  first  subjected  to  the  pressure  of  the 
tumour. 

These  symptoms  are  almost  always  accompanied  by  local 
pain,  and  stiffness  of  the  spine  in  the  neighbourhood  of  the 
tumour. 

Symptoms  of  both  sensory  and  motor  paralysis  appear  sooner 
or  later,  but  these  are  at  first  limited  to  the  region  of  distribu- 
tion of  the  nerves  which  take  origin  from  the  part  of  the  cord 
affected.  These  symptoms  consist  of  circumscribed  anaesthesia, 
often  associated  with  pain  {ancesthesia  dolorosa),  and  local 
paresis  or  paralysis  of  the  corresponding  muscular  groups, 
followed  by  atrophy  and  the  reaction  of  degeneration. 

If  the  cervical  portion  be  the  seat  of  the  affection,  an  upper 
extremity  may  first  be  seized  by  pains,  paraesthesige,  partial 
paralysis,  and  atrophy  before  the  symptoms  of  compression  of 
the  cord  appear.  When  the  dorsal  region  is  the  seat  of  the 
tumour,  the  illness  is  introduced  by  intercostal  neuralgias  and 
herpes  zoster.  Neuralgias  and  trophic  changes  in  the  district 
of  the  lumbar  or  sacral  plexuses  indicate  that  the  lumbar  region 
is  involved. 

After  a  period  of  weeks,  months,  or  years,  according  to  the 
rate  of  growth  of  the  tumour,  the  symptoms  due  to  compression 
and  myelitis  appear  either  gradually  or  suddenly.  When  para- 
plegia occurs  suddenly,  or  in  a  period  of  a  few  hours,  it  is 
generally  caused  by  secondary  myelitis.  If  the  paraplegia 
result  from  the  compression  caused  by  the  slow  growth  of  the 
tumour,  one  lateral  half  of  the  cord  may  be  subjected  to  pres- 
sure, or  the  compression  may  occur  on  the  anterior  or  posterior 
surface  of  the  cord.  Motor  phenomena  predominate  when  the 
anterior  surface  is  chiefly  affected,  and  sensory  phenomena  when 
the  posterior  is  principally  involved.  When  the  cord  is  com- 
pletely compressed,  or  transverse  myelitis  occurs,  the  whole  of 
the  body  below  the  seat  of  the  tumour  becomes  more  or  less 
completely  ana3sthetic  and  paralysed,  and  the  bladder  and 
rectum  are  paralysed,  while  cystitis  and  bed-sores  with  their 
consequences  supervene. 
AA 


402  DISEASES  OF  THE  MEMBRANES  OF  THE 

Symptoms  of  motor  irritation  often  accompany  those  of 
paralysis.  These  usually  consist  of  muscular  twitching  and 
transient  spasms,  and  after  a  time  secondary  degeneration 
occurs,  causing  contracture  of  the  extremities. 

The  reflex  actions,  both  superficial  and  deep,  are  usually 
increased,  but  when  the  grey  substance  becomes  secondarily 
diseased,  or  when  the  tumour  is  situated  in  the  lumbar  region, 
the  reflexes  are  abolished. 

Muscular  atrophy  may  at  first  be  limited  to  the  area  of  dis- 
tribution of  the  nerves,  the  anterior  roots  of  which  are  compressed 
by  the  tumour;  but  after  a  time  all  the  paralysed  muscles 
undergo  rapid  atrophy,  and  their  faradic  contractility  disap- 
pears. Death  is  generally  caused  by  cystitis  and  bed-sores, 
but  when  the  tumour  is  situated  high  up  death  may  be  caused 
by  arrest  of  respiration.  Death  not  unfrequently  results  from 
an  intercurrent  attack  of  pneumonia,  or  spinal  meningitis. 

§  652.  Course,  Duration,  and  Termination. — The  first  stage 
of  the  disease  is  very  insidious  and  may  extend  over  many  years. 
When  once  paraplegia  makes  its  appearance  the  progress  is 
usually  more  rapid ;  but  even  then  years  may  pass  before  death 
occurs.  The  symptoms  fluctuate  greatly  in  severity,  and  the 
entire  duration  of  the  affection  varies  from  eight  months  to  four 
or  five  years ;  although  cases  are  known  which  have  extended 
over  a  period  of  fifteen  years.  The  disease  generally  ends 
fatally,  but  in  the  case  of  syphilomata,  scrofulous  tumours,  and 
inflammatory  new  formations,  complete  or  partial  recovery  may 
take  place.  -» 

§  653.  Diagnosis. — During  the  first  stage  of  the  disease  it 
may  be  inferred  that  there  is  a  circumscribed  lesion  of  the  cord, 
but  it  is  not  possible  to  make  an  accurate  diagnosis  of  tumour. 
When  symptoms  of  a  slowly-developing  compression  of  the  cord 
are  present,  and  when  these  have  been  preceded  by  symptoms 
of  irritation  or  compression  of  the  nerve  roots,  a  tumour  may  be 
suspected. 

The  diagnosis  of  the  nature  of  the  tumour  must  be  made  by 
a  careful  examination  of  all  the  circumstances  of  the  case. 

When  Pott's  disease  or  marked  scrofula  exists,  a  peri-menin- 


SPINAL   COED   AND   MEDULLA   OBLONGATA.  403 

gitic  exudation  may  be  inferred ;  and  when  tbere  is  primary- 
cancer  of  the  vertebra  or  of  some  other  part,  a  carcinomatous 
tumour  may  be  considered  probable ;  while  if  there  be  other 
evidences  of  syphilis  a  gummatous  tumour  is  to  be  expected. 
Echinococcus  may  be  inferred  to  be  present  when  the  parasite 
has  been  found  in  other  organs,  and  neuroma  if  neuromata  are 
found  on  the  peripheral  nerves. 

§  654.  Morbid  Anatomy. 

Fibroma  and  fibrosarcoma  are  usually  small,  oval  tumours, 
3  to  5  cm,  long  and  2  to  4  cm.  thick.  They  spring  from  the 
dura  or  pia  mater,  and  may  be  situated  either  within  or  without 
the  sac  of  the  dura.  They  consist  of  connective  tissue,  with 
more  or  less  abundant  spindle  or  round  cells. 

Sarcoma  occurs  in  every  possible  form,  as  hard  and  soft, 
fibrous  or  cellular,  and  often  as  a  cystosarcoma.  It  generally 
originates  from  the  inner  membranes,  and  is  usually  of  an 
elongated  form,  and  frequently  lobular. 

Myxoma  almost  exclusively  originates  from  the  arachnoid  or 
pia  mater.  It  is  a  soft,  juicy,  lobulated  tumour  of  moderate 
size,  and  pale  colour. 

Psammoma  appears  in  the  form  of  a  small  roundish  or  oval- 
shaped  smooth  or  lobed  tumour,  and  generally  originates  in  the 
soft  membranes.  It  is  really  a  sarcomatous  tumour  with 
granular  concretions  of  lime  imbedded  in  its  substance. 

Lipoma  has  repeatedly  been  found  in  the  vertebral  canal, 
and  may  originate  either  in  the  fatty  tissue  outside  the  dura 
mater  or  from  the  soft  membranes. 

Enchondroma,  of  the  size  of  a  hazel-nut,  and  firmly  adherent 
to  the  dura  mater  and  connected  vertebrae,  has  been  found  by 
Virchow. 

Osteoma,  in  the  form  of  so-called  cartilaginous  discs,  is  very 
common  in  the  arachnoid,  and  diffuse  ossification  of  the  dura 
mater  also  occurs,  but  neither  of  these  can  be  regarded  as 
proper  tumours. 

Multiple  Fibrous  Melanoma  has  been  found  in  the  spinal 
canal  by  Virchow  and  Sander. 

Neuromata  have  been  found  on  the  nerve  roots,  especially  of 


404  DISEASES   OF   THE   MEMBEANES   OF   THE 

the  Cauda  equina.  They  are  generally  false  neuromata,  and  are 
either  multiple,  or  occur  singly. 

Carcinoma  springs  very  rarely  from  the  spinal  membranes. 
These  tumours  are  almost  always  developed  secondarily  by 
extension  from  the  vertebrae  or  neighbouring  parts,  or  by- 
metastasis  from  other  organs. 

Miliary  tubercles  are  found  in  the  soft  membranes,  and 
closely  allied  to  these  are  tumours  which  originate  from  inflam- 
matory, hsemorrhagic,  and  other  processes  in  the  spinal  mem- 
branes or  the  neighbouring  parts,  such  as  peri-pachymeningitic 
exudations,  circumscribed  masses  of  a  purulent  or  caseous 
nature,  scrofulous  exudations  between  the  dura  and  vertebral 
column,  and  hsematoma. 

Syphilomata  usually  consist  of  gummata  of  the  dura  or  pia 
mater. 

Parasitic  growths  are  rarely  met  with  in  the  vertebral  canal. 
Cysticercus  cellulosse  has  been  found  by  Westphal,  and  echino- 
coccus  has  been  occasionally  observed. 

§  C55.  Prognosis. — The  prognosis  is  always  very  serious,  and 
the  more  quickly  the  symptoms  have  developed  the  worse  it  is. 
The  presence  of  carcinoma  warrants  the  worst  prognosis.  lu 
the  inflammatory,  syphilitic,  scrofulous,  and  hgemorrhagic  forms 
the  prognosis  is  more  favourable.  If  paraplegia  be  complete 
the  prognosis  is  hopeless. 

§  656.  Treatment. — The  internal  remedies  from  which  most 
is  to  be  expected  are  iodide  of  potassium  and  mercury. 

The  painful  and  other  distressing  phenomena  must  be  relieved 
by  suitable  remedies. 

(V.)  DEFORMITIES   OF  THE   SPINAL    MEMBRANES. 

§  657.  Spina  Bifida  consists  of  an  abnormal  accumulation 
of  fluid  within  the  cavity  of  the  dura  mater  in  connection  with  a 
greater  or  lesser  deformity  of  the  vertebral  column.  It  presents 
itself  as  a  sac-like  dilatation  and  pouching  of  a  more  or  less 
circumscribed  portion  of  the  cavity  of  the  dura  mater,  which  is 
generally  associated  with  deficiency  or  absence  of  one  or  more 
vertebral  arches.     The  sac  protrudes  like  a  hernia  through  the 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  405 

cleft,  and  raises  the  skia  in  the  form  of  a  tumour  of  variable 
size.  The  seat  of  the  tumour  is  generally  in  the  sacral  and 
lumbar  regions,  and  more  rarely  in  the  dorsal  or  cervical  por- 
tions of  the  cord.  It  is  almost  always  situated  in  the  middle 
line  and  seldom  deviates  to  either  side.  As  a  rule  there  is  only 
one  tumour,  but  several  are  occasionally  present.  They  vary 
in  size  from  a  hazel-nut  to  that  of  a  child's  head,  and  are 
usually  round  or  elliptical  in  form,  but  at  times  may  extend 
over  a  large  portion  of  the  spinal  column.  The  tumour  is 
either  sessile  or  pedunculated,  and  sometimes  subdivided  into 
two  or  lobulated. 

The  skin  over  the  tumoUr  may  be  normal,  or  stretched 
thin,  red,  and  ulcerated,  and  at  times  an  umbilicated  depression 
may  be  seen  at  some  point  on  the  surface  of  the  tumour,  caused 
by  the  insertion  of  the  end  of  the  cord  in  the  interior  of  the  sac. 

The  dura  mater  is  either  thickened  or  thin  and  stretched, 
and  usually  lies  immediately  beneath  the  skin.  The  arachnoid 
usually  encloses  the  fluid,  and  if  hydromyelia  exist,  the  pia  mater 
takes  part  in  the  formation  of  the  sac.  The  neck  of  the  sac  is 
more  or  less  narrow,  and  communicates  with  the  spinal  canal. 
Occasionally  it  may  be  closed  by  adhesions,  so  that  the  external 
sac  forms  a  cystic  tumour. 

The  condition  of  the  spinal  cord  varies  in  different  cases. 
As  a  rule  the  cord  is  normal  and  takes  no  part  in  the  deformity 
except  that  its  lower  extremity  may  be  adherent  to  the  sac. 
The  cord  may  be  lengthened,  and  rendered  thin  and  flat  by  its 
extremity  being  drawn  out  of  the  vertebral  canal.  In  these 
cases  the  nerve  roots  return  along  the  walls  of  the  sac  or  through 
the  fluid.  When  a  hydrorrachis  interna  exists  along  with  the 
spina  bifida,  the  lower  portion  of  the  cord  is  more  or  less  de- 
stroyed, atrophied,  and  the  cavity  of  the  sac  communicates 
directly  with  the  dilated  and  open  central  canal  of  the  cord. 

The  contents  of  the  sac  consist  generally  of  a  light  colourless 
and  clear  fluid,  identical  with  the  normal  cerebro-spinal  fluid, 
and  its  quantity  may  amount  to  from  8oz.  to  21b.  or  more. 

§  658.  Symptoms. — The  most  marked  symptom  at  birth 
consists  of  a  tumour  over  the  vertebral  column,  usually  seated 
in  the  sacral  or  lumbar  region,  and  occasionally  at  a  higher 


406  DISEASES   OF  THE  MEMBRANES   OF   THE 

point  of  the  spinal  column.  When  the  tumour  is  large  the  sac 
may  burst  during  birth,  and  the  child  then  generally  dies  from 
asphyxia  a  few  hours  or  at  most  a  day  or  two  after  birth.  The 
tumour  may  remain  stationary  or  increase  in  size.  In  rare  cases 
it  may  develop  for  the  first  time  after  birth. 

The  tumour  is  tense,  elastic,  fluctuating,  and  when  the  skin 
is  thin  and  stretched  it  may  appear  translucent.  At  times  the 
skin  may  be  ulcerated,  so  that  the  wall  of  the  sac  is  constituted 
by  the  distended  spinal  membranes.  The  sac  can  be  emptied 
by  slow  and  gradual  pressure  except  in  those  cases  in  which 
communication  of  the  spinal  canal  has  been  cut  off  by  closure 
of  the  sac ;  and  if  there  be  coincident  hydrocephalus,  pressure 
on  the  tumour  causes  swelling  and  protrusion  of  the  fontanelles. 
The  swelling  also  increases  on  assuming  the  erect  posture,  and 
during  coughing  and  sneezing.  The  tumour  is  sometimes  sensi- 
tive on  pressure.  It  may  remain  stationary  and  give  rise  to  no 
other  symptoms,  and  the  patient  may  arrive  at  maturity  without 
developing  any  serious  symptoms.  As  a  rule,  however,  it  in- 
creases in  size  and  produces  pressure  on  the  lower  part  of  the 
cord  and  the  cauda  equina,  so  that  the  children  affected  soon 
suffer  from  paraplegia,  incontinence  of  urine  and  faeces^  and  bed- 
sores, and  the  case  soon  terminates  fatally.  When  there  is 
coexistent  hydrorrachis  interna,  paraplegia  and  paralysis  of 
the  sphincters  are  present  from  the  beginning,  and  death 
speedily  results. 

Rupture  of  the  sac  may  be  caused  in  various  ways,  and  is 
followed  by  purulent  inflammation  which  usually  extends  from 
the  sac  into  the  spinal  canal,  and  a  purulent  spinal  meningitis 
results,  which  terminates  fatally  in  a  few  days.  When  the  per- 
foration is  very  minute  and  the  fluid  flows  out  very  slowly,  the 
case  has  been  known  to  terminate  favourably  and  to  lead  to 
the  cure  of  the  disease.  When  the  opening  is  large  and  the 
fluid  is  rapidly  evacuated,  death  may  follow  very  quickly  pre- 
ceded by  general  convulsions. 

§  659,  Diagnosis. — The  diagnosis  is  as  a  rule  exceedingly 
easy,  and  presents  no  difficulty  except  when  the  tumour  is  small 
and  when  the  orifice  of  communication  is  small  or  entirely 
closed.     The  characteristic  signs  of  the  disease  may  be  gathered 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  407 

from  the  symptoms  already  described.  The  sacral  tumour, 
resulting  from  the  displacement  of  the  abdominal  and  pelvic 
viscera,  can  as  a  rule  be  readily  distinguished  from  the  tumour 
of  spina  bifida,  and  the  malformations  and  defects  which  not 
rarely  coexist  with  spina  bifida,  such  as  hydrocephalus,  deformi- 
ties of  the  lower  extremities,  anomalies  of  the  genital  apparatus, 
inversion  of  the  bladder,  with  congenital  fissure  of  the  abdominal 
walls,  can  be  readily  recognised. 

§  660.  Prognosis. — The  prognosis  is  as  a  rule  very  unfavour- 
able. The  majority  of  the  children  die  either  from  accidental 
opening  of  the  sac,  progressive  growth  of  the  tumour,  or  in 
consequence  of  operations  undertaken  to  effect  a  radical  cure. 
The  larger  the  tumour  and  the  higher  its  situation  the  more 
unfavourable  is  the  prognosis.  The  prognosis  is  also  bad  when 
the  orifice  of  communication  is  large,  when  hydromyelia  and 
hydrocephalus  are  associated  with  it,  and  when  the  constitution 
of  the  child  is  feeble. 

§  661.  Morhid  Physiology. — The  origin  of  spina  bifida  is 
still  doubtful.  Some  regard  it  as  being  due  to  dropsy  of  the 
subarachnoidal  space,  or  as  a  primary  dropsy  of  the  central 
canal,  with  disappearance  of  the  cord  and  secondary  widening 
and  distention  of  the  spinal  membranes.  If  these  changes  take 
place  before  the  vertebral  arches  are  closed,  a  cleft  of  the  ver- 
tebral column  may  be  induced.  Others  think  that  the  cleft  of 
the  vertebral  column  is  the  primary  part  of  the  process  and  the 
hydrorrachis  is  developed  at  a  subsequent  period. 

§  662.  Treatment. — The  surgical  operations  which  have  been 
attended  with  the  best  results  are  methodical  compression  of 
the  tumour,  simple  and  repeated  puncture  of  the  sac,  and 
puncture  with  subsequent  injection  of  iodine. 

Simple  puncture  may  be  performed  repeatedly,  and  it  is 
best  effected  by  means  of  the  hypodermic  syringe.  The  sac 
should  not  be  completely  emptied,  and  pressure  should  be  after- 
wards lightly  applied.  For  the  details  of  the  treatment  of  spina 
bifida  surgical  works  must  be  consulted. 


409 


Paet  it.— diseases    of    the    EXCEPHALOy 


CHAPTEE   L 


ANATOMICAL   AND   PHYSIOLOGICAL    DTTEODrCTION. 

The  encephalon  is  invested  with  three  membranes  continnous 
with  those  of  the  spinal  cord.  They  are  named  (1),  dura  mater  ; 
(2),  arachnoid  :   and  '3),  pia  mater. 


§  663.  Lura  Mater. — The  cranial  part  of  the  dnra  mater  is 
adherent  to  the  inner  table  of  the  skidl,  especially  along  the 
lines  of  the  sutures  and  the  margins  of  the  foramina.  Strong 
flattened  prolongations  from  the  inner  surface  of  the  dura  mater 

FiJ.  1=9. 


Fig.  189  (Prom  Ttinier).  I>ijira  Mater  and  Craniid  Shmses. — 1.  Fair  ceretai;; 
2,  Tentoritun ;  3,  3,  Snperior  longitndiDal  sinns ;  4,  laieral  sinus ;  5,  Internal 
jugular  Tein ;  6,  Oodpifcal  sinns ;  7,  8,  Veins  of  Galen ;  9  and  10,  Superior  and 
inferior  petrosal  ^ns ;  11,  CaTemoos  anns ;  12,  CSrcolar  sinns,  which  connects 
the  two  drcolar  annaes  together;  13,  Ophthahnift  Tein,  from  15,.  the  eyeball ; 
14,  Crista  gain  of  etiunoid  bomeL 


410       ANATOMICAL  AND  PHYSIOLOGICAL  INTEODUCTION. 

form  partitions  between  divisions  of  the  encephalon.  These 
partitions  are  respectively  named  the  falx  cerebri,  tentorium, 
cerehelli,  and  falx  cerehelli. 

The  cranial  dura  mater  is  mainly  composed  of  two  layers  of 
fibrous  tissue,  which  separate  from  each  other  along  certain 
lines,  so  as  to  form  tubular  passages,  named  sinuses;  these 
transmit  the  venous  blood  returning  from  the  brain. 

The  sinuses  usually  pass  from  before  backwards,  and  several 
join  opposite  the  internal  occipital  protuberance  at  a  spot  which 
is  called  the  torcular  Herophili.  The  blood  is  drained  from 
the  torcular  by  the  lateral  sinuses,  which  terminate  in  the 
internal  jugular  veins.  The  minute  structure  of  the  membranes 
of  the  brain  is  the  same  as  already  described  in  the  case  of  the 
spinal  membranes. 

§  664.  The  Arachnoid. — The  arachnoid  is  a  delicate  and 
transparent  membrane,  and  between  it  and  the  dura  mater  is  a 
space,,  containing  a  small  quantity  of  limpid  serum,  which 
lubricates  the  smooth  opposed  surfaces  of  the  two  membranes. 
This  space  is  regarded  as  equivalent  to  the  cavity  of  a  serous 
membrane,  and  is  named  the  arachnoid  cavity  or  suh-dural 
space.  The  arachnoid  and  pia  are  separated  by  a  distinct  space 
called  the  suh-arachnoid  space.  The  space  contains  a  limpid 
cerebro  spinal  fluid,  varying  in  quantity  from  two  drachms  to 
two  ounces. 

Pacchionian  Bodies.  —  Clusters  of  granular  bodies  are 
observed  on  each  side  of  the  longitudinal  sinus  imbedded  in 
the  dura  mater,  named  Pacchionian  bodies.  These  bodies  spring 
from  the  arachnoid  membrane,  and  sometimes  attain  a  relatively 
large  size. 

§  665.  Pia  Mater. — The  pia  mater  closely  invests  the  whole 
outer  surface  of  the  brain,  and  dips  in  the  fissures  between  the 
convolutions,  differing  in  this  respect  from  the  arachnoid,  which 
passes  from  the  summit  of  one  convolution  to  that  of  another. 
A  wide  prolongation  of  this  membrane  passes  into  the  interior 
of  the  cerebrum,  named  the  velum  interpositum.  The  pia 
mater  is  prolonged  along  the  roots  of  the  cranial  and  spinal 
nerves  and  filum  terminale.     It  is  the  vascular  membrane  of 


ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION.       411 

the  brain,  and  the  arteries  which  pass  from  it  into  the 
substance  of  the  latter  are  invested  by  it  with  a  loose 
funnel-shaped  sheath,  which  opens  into  the  sub-arachnoid 
space,  and  contains  cerebro-spinal  fluid  (Key  and  Retzius).  The 
ventricles  of  the  brain  are  also  supposed  to  be  in  free  commu- 
nication with  the  sub-arachnoid  space. 

THE  BEAIN  OR  ENCEPHALON. 
The  part  of  the  central  nervous  axis,  which  is  contained 
within  the  cavity  of  the  skull,  is  termed  the  hrain  or  encephalon. 
The  brain  is  conveniently  divided  into  (1),  the  medulla  ob- 
longata; (2),  the  pons  variolii;  (8),  the  cerebellum;  and  (4),  the 
cerebrum. 

§  666.  The  Medulla  Oblongata. — The  medulla  oblongata  is 
the  expanded  upper  end  of  the  spinal  cord,  and  has  already 
been  described. 

§  667.  The  Pons  Variolii. — The  pons  rests  on  the  dorsum 
sellse  of  the  sphenoid  bone,  and  is  marked  on  its  inferior  aspect  by 
a  median  longitudinal  groove,  in  which  the  basilar  artery  lies;  its 
posterior  surface  receives  the  pyramidal  tracts  and  the  upward 
continuation  of  the  anterior  root-zones,  and  the  grey  matter  of 
the  cord;  its  anterior  surface  gives  origin  to  the  two  crura 
cerebri ;  each  lateral  surface  is  in  relation  to  a  hemisphere  of 
the  cerebellum ;  the  superior  surface  forms  in  part  the  upper 
portion  of  the  floor  of  the  fourth  ventricle,  while  the  corpora 
quadrigemina  rest  upon  its  anterior  half. 

Stntdure  of  the  Pons. — The  pons  consists  of  grey  and  white  matter. 
The  greater  portion  of  the  grey  matter  of  the  pons  is  an  upward  continua- 
tion of  the  grey  matter  of  the  spinal  cord  and  medulla  oblongata,  which 
has  been  already  described.  In  addition  to  the  grey  matter  on  the  floor 
of  the  fourth  ventricle,  there  is  a  considerable  quantity  interposed  between 
the  transverse  fibres  of  the  pons.  The  transverse  fibres  derived  from  each 
lateral  lobe  of  the  cerebellum  appear  to  terminate  in  the  interposed  grey 
matter  of  the  opposite  half  of  the  pons. 

The  white  matter  of  the  pons  consists  of  longitudinal  and  transverse 
fibres.  The  longitudinal  fibres  are  the  upward  continuations  of  the 
anterior  pyramids  of  the  medulla,  the  anterior  root-zones  of  the  cord, 
and  probably  also  fibres  ascending  from  the  olivary  body.  The  longi- 
tudinal fasciculi  are  also  reinforced  by  fibres  arising  in  the  pons  itself. 


412       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

The  transverse  fibres  go  from  one  hemisphere  of  the  eerebellum  to  that 
of  the  opposite  side,  although  the  fibres  are  probably  interrupted  in  the 
pons  by  interposed  grey  matter.  These  fibres,  therefore,  constitute  the 
commissural  or  connecting  arrangement,  by  means  of  which  the  two 
hemispheres  of  the  cerebellum  become  anatomically  continuous  with  one 
another. 

THE   CEEEBELLUM. 

§  668. — The  cerebellum  occupies  the  iDferior  occipital  fossae. 
It  consists  of  two  lateral  hemispheres  joined  together  by  a 
median  portion  called  the  vermiform  process.  On  the  superior 
surface  of  the  cerebellum  this  is  a  mere  elevation,  but  on  its 
inferior  surface  it  forms  a  well-marked  projection,  named  the 
inferior  vermiform  process.  This  process  lies  at  the  bottom 
of  a  deep  fossa  (vallecula),  which  is  prolonged  to  the  posterior 
border  of  the  cerebellum,  and  forms  there  a  deep  notch,  in 
which  the  falx  cerebelli  is  lodged. 

The  Peduncles. — The  cerebellum  is  connected  below  with  the 
medulla  oblongata  by  the  two  restiform  bodies  which  form  its 
inferior  peduncles.  The  crossed  connection  of  the  fibres  of  the 
inferior  peduncles  of  the  cerebellum  with  the  olivary  bodies 
has  already  been  described.  The  cerebellum  is  connected  with 
the  corpora  quadrigemina  and  crura  cerebri  by  two  superior 
peduncles.  The  greater  portion  of  the  fibres  of  the  superior 
peduncles  decussate  in  the  upper  end  of  the  pons  and  in  the 
tegmenta,  the  fibres  of  one  side  becoming  connected  with  the 
red  nucleus  of  the  tegmentum  of  the  opposite  side.  The  trans- 
verse fibres  of  the  pons  form  the  middle  peduncles  of  the 
cerebellum. 

Folia. — The  surface  of  the  cerebellum  consists  of  numerous 
lamina}  or  folia,  which  are  separated  by  fissures  or  sulci  of  diffe- 
rent depths. 

Fissures. — The  great  horizontal  fissure  begins  behind  the 
middle  peduncles,  passes  horizontally  backwards  round  the 
circumference  of  the  cerebellum,  dividing  its  tentorial  and 
occipital  surfaces.  From  this  primary  fissure  numerous  others 
proceed,  and  some  that  are  constant  in  their  position  and  deeper 
than  the  rest  have  been  described  as  separating  the  cerebellum 
into  lobes. 

Lohes. — The  tentorial  surface  is  subdivided  into  two  smaller 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       413 

lobes,  named  anterior  superior  and  posterior  superior.  On 
the  occipital  surface  each  hemisphere  is  subdivided  from  behind 
forwards  into  the  posterior  inferior  lohe,  the  slender  lohe, 
the  hiventral  lohe,  and  the  flocculus.  Immediately  internal 
to  the  biventral  lobe  is  the  amygdala  or  tonsil,  which  forms  the 
lateral  boundary  of  the  anterior  part  of  the  vallecula.  The  infe- 
rior vermiform  process  is  subdivided  into  a  posterior  part  or 
pyramid,  an  elevation  or  uvula  situated  between  the  two  tonsils, 
and  an  anterior  pointed  process  or  nodule.  Stretching  between 
the  two  flocculi,  and  attached  midway  to  the  sides  of  the  nodule, 
is  a  thin,  white,  semi-lunar-shaped  plate  of  nervous  matter,  called 
the  posterior  medullary  velum,  whilst  the  layer  of  grey  matter 
stretching  between  the  uvula  and  tonsil  on  each  side  is  called 
the  furrowed  band. 

§  669.  Internal  Structure. — The  cerebellum  consists  of  both  grey  and 
white  matter.  The  grey  matter  forms  the  exterior  or  cortex,  while  the 
white  forms  the  interior  of  the  organ.  A  vertical  section  through  the 
cerebellum  presents  an  arborescent  appearance  known  by  the  name  of 
arbor  vitce.  Independent  masses  of  grey  matter  are  found  in  the  interior 
of  the  cerebellum.  If  the  hemisphere  be  cut  through  to  the  outer  side  of 
the  median  lobe,  a  nucleus  of  grey  matter  is  observed  similar  in  its  arrange- 
ment to  the  olivary  body,  and  named  the  corpus  dentatum.     It  encloses 


Fig.  190. 


Fig.  190  (From  Turner).  The  Occipital  Surface  of  the  Cerebellum.— a,  Vallecula; 
6,  Pyramid ;  c,  Uvula ;  d.  Nodule ;  e,  e,  Margin  of  tentorial  surface ;  /,  /, 
Great  horizontal  fissure ;  g,  g,  Posterior  inferior  lobes ;  h,  h,  Slender  lobes ; 
k,k,  Biventral  lobes ;  I,  Tonsil;  m,  Flocculus;  ri,  Posterior  medullary  velum; 
0,  Cut  surface  from  which  the  left  tonsil  has  been  detached. 


414       ANATOMICAL  AND  PHYSIOLOGICAL  INTEODUCTION. 

white  fibres  which  leave  the  interior  of  the  corpus  at  its  inner  and  lower 
aides.  Stilling  has  described  two  grey  masses  situated  in  the  anterior 
end  of  the  inferior  vermiform  process  which  he  named  roof  nuclei. 

The  white  matter  is  for  the  most  part  continuous  with  the  fibres  of  the 
peduncles  of  the  cerebellum.  The  fibres  of  the  inferior  peduncles  pass 
upwards  to  join  the  grey  matter  of  the  superior  surface  of  the  cerebellum, 
especially  in  the  median  lobe.  They  are  also  connected  with  the  corpus 
dentatum  and  roof  nuclei.  Those  of  the  superior  peduncles  descend  from 
the  corpora  quadrigemina  and  reach  the  grey  cortical  matter,  more  espe- 
cially that  of  the  inferior  surface  of  the  cerebellum,  and  they  are  also  con- 
nected with  the  corpus  dentatum.  The  fibres  of  the  middle  peduncles 
terminate  chiefly  in  the  cortex  of  the  lateral  lobes.  The  cerebellum  also 
contains  fibres  which  connect  difierent  parts  of  its  grey  matter  with  one 
another,  named  fibrce  proprice.  Stilling  describes  a  median  fasciculus,  the 
fibres  of  which  connect  the  superior  and  inferior  vermiform  processes. 
Other  fibres  cross  the  median  plane  to  unite  symmetrical  regions  of  the 
lateral  lobes.  Meynert  describes  a  cerebellar  origin  of  the  auditory  and 
fifth  nerves. 

Minute  Structure. — The  grey  matter  of  the  cortex  is  divided  into  an 
external  grey  or  cellular  layer,  and  an  internal  rust-coloured  layer  of  about 
equal  thickness.  The  external  layer  consists  of  a  delicate  matrix  contain- 
ing cells  and  fibres.  Most  of  the  fibres  have  a  direction  at  right  angles 
to  the  surface,  the  majority  of  them  being  the  processes  of  Purkinje's 
cells,  to  be  immediately  described.  Of  the  cells  some  are  small,  and 
appear  to  belong  to  the  connective-tissue  matrix,  while  others  are  larger, 
and  probably  connected  with  the  processes  of  Purkinje's  cells.  The 
inner  part  of  the  external  layer  contains  fibres  which  run  parallel  with 
the  surface. 

The  inner  or  granule  layer  consists  of  granule-like  corpuscles,  which 
lie  in  dense  groups  in  a  gelatinous  matrix,  containing  a  plexus  of  fine 
nerve  fibres.  Some  are  round,  while  others  are  angular  and  possess  a 
protoplasmic  envelope  with  processes,  which  are  supposed  to  be  connected 
with  the  plexus  of  fine  nerve  fibres  amongst  which  they  lie. 

The  cells  of  Purkinje  lie  in  a  single  layer,  between  the  outer  and  inner 
layers  of  the  cortex.  Most  of  them  are  flask-shaped  bodies,  containing  a 
spherical  nucleus  and  nucleolus.  The  long  axis  of  the  cell  is  generally 
directed  at  right  angles  to  the  surface.  From  the  external  surface  of  the 
cells  two  processes  are  given  ofi" ;  these  pass  out  towards  the  surface  and 
divide  repeatedly  in  their  course.  The  finer  subdivisions  of  these  pro- 
cesses have  been  said  to  curve  back  towards  the  granule  layer,  where, 
according  to  Boll,  they  form  a  network  of  extreme  minuteness,  from  which 
it  is  believed  that  nerve  fibres  arise.  From  the  inner  end  of  the  cell 
another  fibre  is  given  ofi";  it  is  unbranched,  passes  into  the  granule  layer, 
and  is  supposed  to  be  continuous  with  the  axis  cylinder  of  a  nerve  fibre. 

The  medullary  centre  consists  of  nerve  fibres  arranged  in  parallel  or 
interlacing  bundles.      They  form  the  central  stem  of  the  folia,  whence 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       415 

they  radiate  into  the  cortex.  They  disappear  in  the  granule  layer,  and 
are  commonly  believed  to  be  continuous  with  the  inner  processes  of 
Purjdnjd's  cells. 

THE    CEREBRUM. 

§  670.  The  cerebrum  constitutes  the  largest  division  of  the 
encephalon,  and  lies  above  the  level  of  the  tentorium.  It  con- 
sists of  a  narrow  constricted  portion — the  crura — of  certain 
basal  ganglia — the  corpora  quadrigemina,  optici  thalami,  and 
corpora  striata — and  of  an  upper  expanded  portion — the  cere- 
bral hemispheres. 

§  671.  Exterior  of  the  Cerebrum. — The  cerebrum  is  ovoid  in 
shape  and  presents  superiorly,  anteriorly,  and  posteriorly  a  deep 
median  longitudinal  fissure,  which  subdivides  it  into  two 
hemispheres.  The  two  hemispheres  are  connected  across  the 
median  plane  by  the  corpus  callosum.  The  outer  surface  of 
each  hemisphere  is  convex,  and  adapted  in  shape  to  the  con- 
cavity of  the  inner  table  of  the  cranial  bones.  Its  inner  sur- 
face is  flat,  and  is  separated  from  the  opposite  hemisphere  by 
the  falx  cerebri.  The  under  surface,  where  it  rests  on  the  tento- 
rium, is  concave,  and  is  separated  by  that  membrane  from  the 
cerebellum  and  pons.  From  the  front  of  the  pons  two  strong 
white  bands,  the  crura  cerebri  or  cerebral  peduncles,  pass  for- 
wards and  upwards  to  enter  the  basal  ganglia  of  their  respective 
hemispheres.  The  optic  tracts  wind  round  each  crus,  and  con- 
verge in  front  to  form  the  optic  commissure  from  which  the  two 
optic  nerves  arise.  The  crura  cerebri,  optic  tracts,  and  optic 
commissure  enclose  a  lozenge-shaped  space  which  includes  from 
behind  forwards  the  posterior  perforated  space,  the  corpora 
albicantia,  and  the  tuber  cinereum,  from  which  the  infundi- 
bulum  projects  to  join  the  pituitary  body.  Immediately  in 
front  of  the  optic  commissure  is  a  grey  layer,  the  lamina 
cinerea  or  lamina  terminalis  of  the  third  ventricle;  and  between 
the  optic  commissure  and  the  inner  end  of  each  Sylvian  fissure 
is  a  grey  spot  perforated  by  small  arteries,  the  anterior  per- 
forated space. 

The  peripheral  part  of  each  hemisphere  consists  of  grey 
matter,  and  exhibits  a  characteristic  folded  appearance,  known 
as  the  convolutions  or  gyri  of  the  cerebrum.  The  convolutions 
are  separated  from  each  other  hy  fissures  or  sulci,  some  of 


416       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


which  are  considered  to  subdivide  the  hemispheres  into  lobes, 

whilst  others  separate  the  convolutions  of  each  lobe  from  each 

other.  * 

Fig.  191. 

2 


Tig.  191  (From  Henle's  Anatomie).    Base  of  the  Srain.—F,  Pons;  Tho,  Optic 
thalamus  ;  Lpp,  Posterior  perforated  space  ;  Jn,  Island  of  Reil. 


Tbo,  Olfactory  bulb. 

Let,  Lamina  cinerea.      Tc,  Tuber  cinereum. 

CcP,  Knee  of  the  corpus  callosum. 

Pec,  Peduncles  of  the  corpus  callosum. 

Cba,  Commissure  of  the  corpus  callosum. 

Spa,  Anterior  perforated  space. 


Cc,  Corpora  albicantia. 

Gf,  Gyrus  fornicatus. 

T,  Tegmentum. 

B,  Crusta. 

Sr,  Substantia  reticularis. 

Mo,  Medulla  oblongata. 


The  Roman  letters  indicate  the  corresponding  cranial  nerves  :  I,  Olfactory 
nerve  ;  Ji,  Olfactory  bulb  ;  II,  Optic  nerve  ;  IIS  Optic  tract ;  *,  Sylvian  fissure ; 
**,  the  point  of  the  temporo-sphenoidal  lobe  dravm  back  to  show  the  continuity  of 
this  lobe  with  the  posterior  convolution  of  the  Island  of  Reil. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       417 

§  672.  Lobes  of  the  Cerebrum. — They  are  five  in  number, 
named  respectively  frontal,  parietal,  occipital,  temporo- 
sphenoidal,  and  central.  The  divisions  between  these  lobes 
are  marked  partly  by  certain  conspicuous  fissures,  and  partly  by 
artificial  lines. 

§  673,  The  Primary  Fissures. — The  Sylvian  fissure  is  the 
first  to  appear  in  the  development  of  the  hemisphere.  It  passes 
obliquely  along  the  outer  surface  of  the  hemisphere  from  before 
backwards,  and  upwards.  In  man  it  divides  into  two  rami — 
the  posterior  or  horizontal  (Fig.  192,  S'),  and  the  ascending  or 
anterior  (Fig.  192,  S").  The  portion  included  between  these 
two  branches  receives  the  name  of  the  operculum,  and  forms 
the  roof  of  the  central  lobe  or  Island  of  Reil.  Below  the  fissure 
of  Sylvius  lies  the  temporo- sphenoidal  lobe,  and  above  and 
in  front  of  it  the  parietal  and  frontal  lobes.  The  frontal  is 
separated  from  the  parietal  lobe  by  the  fissure  of  Rolando 
(Fig.  192,  c)  or  Central  Sulcus.  It  extends  from  the  longitu- 
dinal fissure  obliquely,  downwards  and  forwards,  along  the  outer 
surface  of  the  hemisphere  towards  the  Sylvian  fissure.  The 
parieto-occipital  fissure  commences  at  the  longitudinal  fissure, 
about  two  inches  from  the  posterior  end  of  the  hemisphere.  It 
passes  down  the  inner  surface  of  the  hemisphere,  and  also  trans- 
versely outwards  for  a  short  distance  on  the  outer  surface,  and 
separates  the  parietal  and  occipital  lobes  from  each  other. 

§  674.  Secondary  Fissures  and  Convolutions. — The  temporo- 
sphenoidal  lobe  presents  on  the  outer  surface  of  the  hemispheres 
three  parallel  convolutions,  named  the  superior  (Fig.  192,  Tl), 
middle  (Fig.  192,  T2),  and  inferior  temporo-sphenoidal  (Fig. 
192,  T3)  convolutions. — The  fissure  which  separates  the  superior 
and  middle  of  these  convolutions  is  called  the  parallel  fissure. 

The  occipital  lobe  also  consists  of  three  parallel  convolutions, 
named  superior  (Fig.  192,  01),  middle  (Fig.  192,  02),  and 
inferior  (Fig.  192,  03)  occipital  convolutions. 

The  frontal  lobe  consists  of  three  convolutions  arranged  in 

parallel  tiers  from  above  downwards,  and  named  superior  (Fig, 

192,  Fl),  middle  (Fig.  192,  F2),  and  inferior  (Fig.  192,  F3) 

frontal  convolutions.     These  are  prolonged  anteriorly  to  the 

BB 


418       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

orbital  surface  of  the  frontal  lobe,  and  terminate  posteriorly  in 
the  convolution  which  forms  the  anterior  boundary  of  the 
fissure  of  Rolando,  named  the  ascending  frontal  convolution 
{Fig.  192,  A). 

The  secondary  fissures  which  separate  the  superior,  middle, 
and  inferior  frontal  convolutions  from  one  another  are  the 
supero- frontal  (Fig.  192,  /I),  and  the   in fero -frontal  {Fig. 

Fig.  192. 


Fig.  192  lEcker).  Lateral  View  of  the  Human  Brain.  — F,  Frontal  lobe.  P, 
Parietal  lobe.  O,  Occipital  lobe.  T,  Temporo-sphenoidal  lobe.  S,  Fissure 
of  Sylvius,  S'  Horizontal,  S"  Ascending  ramus  of  the  same.  _  c,  Sulcus  cen- 
tralis, or  fissure  of  Rolando.  A,  Anterior  central  or  ascending  frontal  con- 
volution. B,  Posterior  central  or  ascending  parietal  convolution.  Fj  Superior, 
Fa  Middle,  and  Fg  Inferior  frontal  convolutions,  f^  Superior  and /j  Inferior 
frontal  sulcus  ;  fa  Sulcus  prae-centralis.  Pj  Superior  parietal  or  postero-parietal 
lobule ;  Pa  Inferior  parietal  lobule,  viz.  P.^  Gyrus  supra-marginalis,  P^'  Gyrus 
angularis.  ip,  Sulcus  intra-parietalis.  cm,  Termination  of  the  calloso-marginal 
fissure.  Oi  First,  O2  Second,  O3  Third  occipital  convolutions.  _  po,  Parieto- 
occipital fissure.  0,  Sulcus  occipitalis  transversus  ;  0^  Sulcus  occipitalis  longi- 
tudinalis  inferior.  T^  First,  Ta  Second,  T,  Third  temporo-sphenoidal  convo- 
lutions,    ti  First,  «2  Second  temporo-sphenoidal  fissures. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       419 

192,  /2),  while  the  continuity  of  the  three  frontal  convo- 
lutions with  the  ascending  frontal  one  is  interrupted  by  the 
antero-parietal  sulcus,  or  Sulcus  Proe-centralis  {Fig.  192, /3). 
The  ascending  ramus  of  the  fissure  of  Sylvius  [Fig.  192,  S")  also 
interrupts  the  continuity  of  the  inferior  frontal  with  the  ascend- 
ing frontal  convolution. 

Fig.  193. 


Fig.  193  (After  Ecker  and  Duret).     View  of  the  Brain  from  below. 


Fl,  Grynis  Rectus. 

F2,  Middle  frontal  convolution. 

F3,  Inferior  frontal  convolution. 

/4,  Sulcus  olfactorius. 

/5,  Sulcus  orbitalis. 

2*2,  Second  or    middle   temporo-sphe- 

noidal  convolution. 
T3,  Third   or    inferior    temporo-sphe- 

noidal  convolution. 
Fi,  Gyrus  occipito-temporalis  lateralis 

(lobulus  fusiformis). 
T5,  Gyrus  occipito-temporalis  medialis 

(lobulus  lingualis). 


ti,  Sulcus  occipito-temporalis  inferio 
t'S,  Sulcus  temporo-sphenoidalis  inferior. 
t2,   Sulcus    temporo-sphenoidalis     m©" 

dialis. 
po,  Parieto-occipital  fissure. 
oc,  Calcarine  fissure. 
ff,  Gyrus  hippocampi. 
U,  Gyrus  uncinatus. 
Ch,  Optic  chiasma. 
cc,  Corpora  albicantia. 
KK,  Crura  cerebri. 
V,  Corpus  callosum. 


420       ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION. 

The  orbital  surface  or  orbital  lobule  presents  two  fissures — 
the  olfactory  sulcus,  -which  runs  parallel  with  the  longitudinal 
fissure  and  lodges  the  olfactory  bulb,  and  the  orbital  sulcus 
{Fig.  193,  /5),  which  lies  in  the  centre  of  the  lobule  and  is  often 
triradiate.  The  straight  convolution  {Fig.  193,  Fl)  lies  between 
the  longitudinal  fissure  and  the  olfactory  sulcus,  and  is  con- 
tinuous at  its  anterior  extremity  with  the  superior  frontal 
convolution.  Three  convolutions  are  sometimes  described  as 
lying  around  the  orbital  sulcus,  named,  according  to  their 
positions,  the  internal,  the  anterior,  and  the  posterior  orbital 
convolutions. 

The  parietal  lobe  presents  several  convolutions.  The  most 
anterior  is  the  ascending  parietal  convolution  {Fig.  192,  B), 
which  lies  immediately  behind  the  fissure  of  Rolando,  and  is 
bounded  posteriorly  by  a  sulcus  termed  the  intra-parietal 
sulcus  {Fig.  192,  ip).  The  postero-parietal  convolution  or 
superior  parietal  lobule  {Fig.  192,  PI)  springs  from  the  upper 
end  of  the  back  of  the  ascending  parietal  convolution,  and  forms 
the  boundary  of  the  longitudinal  fissure,  extending  as  far  back 
as  the  parieto-oceipital  fissure.  The  supra-marginal  convo- 
lution {Fig.  192,  P2)  springs  from  the  lower  end  of  the  ascend- 
ing parietal  convolution  at  its  posterior  aspect,  and  arches  round 
the  posterior  extremity  of  the  Sylvian  fissure.  The  angular 
gyrus  {Fig.l92,'P2')  is  continuous  with  the  supra-marginal  con- 
volution, and  bends  round  the  posterior  extremity  of  the  parallel 
fissure.  The  supra-marginal  convolution  and  angular  gyrus  have 
together  been  described  as  the  inferior  parietal  lobule  (Ecker), 
or  the  convolutions  of  the  parietal  eminence  (Turner).  They 
occupy  the  hollow  in  the  parietal  bone  which  corresponds  with 
the  parietal  eminence. 

The  occipital  is  connected  with  the  parietal  lobe  by  two 
annectant  or  bridging  gyri.  The  superior  annectant  gyrus 
passes  between  the  postero-parietal  and  the  superior  occipital 
convolutions,  whilst  the  second  annectant  gyrus  connects  the 
middle  occipital  with  the  angular  gyrus.  Two  annectant  gyri 
also  pass  from  the  inferior  occipital  convolution  to  the  lower 
convolutions  of  the  temporo-sphenoidal  lobe. 

The  central  lobe,  or  Island  of  Reil,  lies  deeply  within  the 
fissure  of  Sylvius,  being  invisible  except  when  the  lips  of  the 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       421 

fissure  are  separated.  It  consists  of  about  six  short,  straight 
convolutions  (gyri  operti),  which  radiate  outwards  from  the 
anterior  perforated  space.  The  anterior  convolution  is  con- 
tinuous with  the  adjacent  posterior  orbital  convolution,  while 
the  posterior  convolution  joins  the  temporo- sphenoidal  lobe. 
Externally,  the  island  of  Reil  is  separated  by  a  deep  sulcus 
from  the  contiguous  convolutions  of  the  operculum,  and  it 
covers  the  lenticular  nucleus  of  the  corpus  striatum. 

The  small  convolutions  which  lie  behind  the  parieto-occipital 
fissure  form  the  internal  convolutions  of  the  occipital  lobe, 
named  the  internal  occipital  lobule,  or  cuneus  {Fig.  194,  Oz). 
Those  which  lie  immediately  in  front  of  the  internal  part  of 
the  parieto-occipital  lobule  and  between  it  and  the  curved 
posterior  extremity  of  the  calloso- marginal  fissure  are  called 

Fig.  194. 


Fig.  194  (Ecker).  View  of  the  Median  J  sped  of  the  Bight  Hemisphere  of  the  Human 
Brain. — OC,  Corpus  callosum,  longitudinally  divided.  Gf,  Gyrus  fornicatus. 
H,  Gyrus  hippocampi,  h,  Sulcus  hippocampi.  U,  Uncinate  gyrus,  cm, 
Sulcus  calloso-marginalis.  Fi,  Median  aspect  of  the  first  frontal  convolution. 
0,  Terminal  portion  of  the  sulcus  centralis,  or  fissure  of  Rolando.  A,  Anterior ; 
B,  Posterior  central  convolution.  Pi",  Prsecuneus.  Oz,  Cuneus.  Po,  Parieto- 
occipital fissure,  o,  Sulcus  occipitalis  transversus.  oc,  Calcarine  fissure, 
oc',  Superior ;  oc",  Inferior  ramus  of  the  same.  D,  Gyrus  descendens.  _  T4, 
Gyrus  occipito-temporalis  lateralis  (lobulus  fusiformis).  T»,  Gyrus  occipito- 
temporalis  medialis  llobvilus  lingualis). 


422       ANATOMICAL  AND  PHYSIOLOGICAL  INTKODUCTION. 

the  prcBcuneus  or  quadrilateral  lobule  {Fig.  194,  Pi").  The 
paracentral  lobule  lies  immediately  in  front  of  the  prsecuneus. 
It  consists  of  the  upper  extremities  of  the  ascending  frontal 
and  parietal  convolutions,  viewed  from  the  internal  surface  of 
the  hemisphere.    It  is  cutomary  to  name  the  convolution  which 


Fig.  195  (  From  Henle's  Anatomie  ).     Internal  View  of  the  Hemisphere  of 
the  Oerebrum. 

CcP,  Knee  of  the  callosum. 


Ftp,  Posterior  transverse  fissure, 

Vq,  Fourth  ventricle. 

Mo,  Medulla  oblongata. 

P,  Pons. 

Cca,  Corpora  caudicantia. 

Tc,  Tuber  cinereum. 

H,  Pituitary  body. 

II',  Optic  tract. 

II,  Optic  nerve. 

Let,  Lamina  cinerea, 


CcP,  Corpus  callosum. 

Ccl*,  Splenium  of  the  corpus  callosum. 

SI,  Septum  lucidum. 

Com,  Median  commissure  of  the  third 

ventricle. 
SM,  Sulcus  Monroi. 
Cop,  Posterior  commissure  of  the  third 

ventricle. 
Cn,  Pineal  gland. 


Coa,  Anterior  commissure  of  the  third  Lq,  Corpora  quadrigemina. 

ventricle.  A,  Aqueduct  of  Sylvius. 

Cba,   Commissure  of   the  corpus  cal-  Fta,  Anterior  transverse  fissure. 

losum.  Vma,  Anterior  medullary  velum 

CclS  Eostrum.  Cbl,  Cerebellum. 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.       423 

extends  forwards  from  the  parieto-occipital  fissure  along  the 
margin  of  the  longitudinal  fissure  to  the  anterior  extremity 
of  the  hemisphere,  and  which  then  turns  back  to  the  anterior 
perforated  space,  the  marginal  convolution. 

The  internal  is  not  divided  into  lobes  like  the  external 
surface,  but  the  convolutions  may  be  studied  in  connection 
with  the  corpus  callosum  and  with  certain  fissures  situated  in 
this  surface. 

The  parieto -occipital  fissure  (Fig.  194,  Po)  is  continuous  with 
the  fissure  of  the  same  name  on  the  external  surface.  It  ex- 
tends downwards  and  forwards,  and  blends  with  the  calcarine 
fissure.  The  calcarine  fissure  {Fig.  194,  oc)  commences  at  the 
posterior  extremity  of  the  hemisphere,  usually  in  a  bifurcated 
manner,  and  extends  forwards  to  terminate  beneath  the  pos- 
terior extremity  of  the  corpus  callosum.  It  marks  the  position 
of  the  calcar  avis  or  hippocampus  minor  in  the  posterior  cornu 
of  the  lateral  ventricle.  The  calloso-marginal  fissure  (Fig. 
194,  cm)  commences  beneath  the  anterior  extremity  of  the 
corpus  callosum,  and  passes  forwards,  upwards,  backwards, 
round  the  corpus  callosum,  terminating  behind  the  superior 
extremity  of  the  ascending  parietal  convolution. 

The  convolution  which  immediately  bounds  the  corpus 
callosum  is  termed  the  gyrus  fornicatus  (Fig.  194,  Gf).  It 
begins  at  the  anterior  perforated  space,  turns  round  the  an- 
terior end  of  the  corpus  callosum,  extends  parallel  to  its  upper 
surface,  and  then  turns  round  its  posterior  end.  It  is  sepa- 
rated from  the  corpus  callosum  by  the  callosal  fissure,  and 
from  the  marginal  convolution  by  the  calloso-marginal  fissure. 
The  posterior  end  of  the  gyrus  fornicatus  curves  downwards 
and  then  forwards  under  the  name  of  gyrus  uncinatus,  or 
gyrus  hippocampi  (Fig.  194,  H),  to  the  tip  of  the  inner  sur- 
face of  the  temporo-sphenoidal  lobe.  The  uncinate  gyrus  ends 
anteriorly  in  a  crook-like  extremity,  or  crochet,  named  the 
uncus  gyri  fornicati,  or  subiculum  cornu  ammonis  (Fig. 
194,  U).  The  gyrus  is  separated  anteriorly  by  a  narrow-curved 
fissure,  called  hippocampal  or  dentate  fissure,  from  a  white 
band  named  the  taenia  hippocampi.  This  band  possesses  a 
free-curved  border,  round  which  the  pia  mater  enters  the 
lateral  ventricle  through  the  great  transverse  fissure   of  the 


424       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

cerebrum.  The  grey  matter  of  the  gyrus  hippocampi  termi- 
nates at  the  bottom  of  the  hippocampal  fissure  in  a  well-defined 
dentated  border  named  the  fascia  dentata.  The  hippocampal 
fissure  marks  the  position  of  an  eminence  in  the  descending 
cornu  of  the  ventricle  called  the  MppocaTnpus  major. 

Running  along  the  internal  aspect  of  the  occipital  and  tem- 
poro-sphenoidal  lobes  is  a  fissure  termed  the  collateral,  which 
marks  the  position  of  the  collateral  eminence  in  the  lateral  ven- 
tricle. It  separates  two  convolutions  from  each  other  which 
connect  the  occipital  and  temporo-sphenoidal  lobes  with  each 
other,  and  are  therefore  named  the  occipito-temporal  convo- 
lutions {Fig.  194,  T4,  T5).  The  upper  of  these  is  termed  the 
gyrus  occipito-temporalis  medialis,  or  lingual  lobule  (T5); 
while  the  lower  is  named  the  gyrus  occipito-temporalis 
lateralis,  or  lobulus  fusiformis  (T4). 

§675.  KELATIONS  OF  THE   CONVOLUTIONS  TO  THE   SKULL. 
The  relations  of  the  primary  fissures  and  convolutions  of  the 
brain  with  relation  to  the  skull   have  been   investigated  by 
Broca,  Fdrd,  Turner,  and  others.     The  following  is  an  abstract 
of  Turner's  conclusions  : — 

Befinite  Landmarks  on  the  Surface  of  the  Skull. — The  following  struc- 
tures and  markings  are  easily  recognised  on  the  skull.  The  external 
occipital  protuberance  {Fig.  196,  o),  the  parietal  (P)  and  frontal  (F)  emi- 
nences, and  the  external  angular  process  of  the  frontal  bone  (A),  the 
coronal  (c)  and  lambdoidal  {I),  squamous  (s),  squamoso-sphenoid  {ss), 
and  parieto -sphenoid  sutures  {ps),  and  the  curved  line  of  the  temporal 
ridge  {t). 

Primary  Areas  oj  the  Skull. — The  coronal  suture  (c)  forms  the  posterior 
boundary  of  the  frontal  area.  A  vertical  line  {Fig.  196,  2)  drawn  from  the 
squamous  suture  (s)  upwards  through  the  parietal  eminence  (P)  to  the 
sagittal  suture  lies  almost  parallel  to  the  coronal  suture,  and  subdivides 
the  parietal  region  into  an  antero-parietal  {Fig.  196,  SAP  +  lAP) 
and  di. postero-parietal area,  {Fig.  196,  SPP  +  IPP).  The  occipital  region 
lies  between  the  lambdoidal  suture  {I)  and  the  occipital  protuberance  (o), 
with  the  superior  curved  line  extending  from  it  {Fig.  196,  o). 

Secondary  Areas  of  the  Skull. — These  four  primary  divisions  of  the  skull 
may  be  subdivided  into  secondary  areas.  The  temporal  ridge  {Fig.  196,  f) 
starting  from  the  external  frontal  process  curves  backwards  across  the 
frontal  (A),  antero-parietal,  and  post-parietal  areas  to  the  internal  angle  of 
the  occipital  bone,  and  subdivides  each  of  these  regions  into  an  upper  and 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       425 

a  lower  area.  The  upper  frontal  area,  which  includes  all  the  frontal  regions 
above  the  temporal  ridge,  is  again  divided  by  a  line  drawn  vertically 
upwards  and  backwards  from  above  the  orbit  through  the  frontal  eminence 
to  the  coronal  suture  {Fig.  196,  c).  This  line  divides  the  upper  frontal 
area  into  a  super o- frontal  (SF)  and  a  mid-frontal  area  (MF). 

Two  other  areas  remain  to  be  described.  These  are  concealed  by  the 
temporal  muscle,  and  are  limited  superiorly  by  the  squamoso-parietal, 
sphenoido-parietal,  and  fronto-sphenoidal  sutures.  The  lines  of  the  sutures 
naturally  divide  this  area  into  a  squamoso-temporal  (Sq)  and  ali-sphenoidal 
area  (AS). 

The  following  then  are  the  secondary  areas  of  the  skull :  Superior 
Frontal  (SF),  Middle  Frontal  (MF),  Inferior  Frontal  (IF),  Upper 
Antero-Parietal  (SAP),  Lower  Antero- Parietal  (lAP),  Upper  Postero- 
Parietal  (SPP),  Lower  Postero-Parietal  ('IPP),  Occipital  (0),  Squamoso- 
Temporal  (Sq),  and  Ali- Sphenoidal  (AS). 

Fig.  196. 


Fig.  196  (Ferrier).  Lateral  View  of  the  Human  Skull.— A,  The  external  angular 
process  of  the  frontal  bone.  F,  The  frontal  eminence.  P,  The  parietal  eminence, 
o,  The  occipital  protuberance,  c,  The  coronal  suture.  I,  The  lambdoidal 
suture,  s,  The  squamous  suture,  i,  The  temporal  ridge,  /s,  The  fronto-sphenoid 
suture,  ps.  The  parieto-sphenoid  suture,  ss.  The  squamoso-sphenoid  suture. 
pm.  The  parieto-mastoid  suture.  1,  Frontal  line.  2,  Parietal  line.  SF,  MF, 
IF,  The  supero-,  mid-,  and  infero-frontal  subdivisions  of  the  frontal  area. 
SAP,  The  supero-antero-parietal  area.  lAP,  The  infero-antero-parietal  area. 
SPP,  The  supero-postero-parietal  area.  IPP,  The  infero-postero-parietal  area. 
O,  The  occipital  area,  Sq,  The  squamoso-temporal  area.  AS,  The  ali-sphenoid 
area. 


426       ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

RELATIONS   OF  THE   CONVOLUTIONS   AND   FISSURES   OF  THE 
BRAIN  TO  THE  AREAS  OF  THE  SKULL. 

§  G76.  The  fissure  of  Sylvius  {Fig.  197,  SS)  commences 
behind  the  posterior  border  of  the  lesser  wing  of  the  sphenoid, 
and  courses  upwards  and  backwards  below  the  greater  wing  of 
the  sphenoid,  where  it  articulates  with  the  anterior  inferior 
angle  of  the  parietal  bone,  and  then  appears  in  the  lower  part 
of  the  inferior  antero-parietal  region.  The  fissure  of  Rolando 
{Fig.  197,  B,)  lies  in  the  antero-parietal  region,  both  in  its 
superior  and  inferior  divisions,  its  upper  extremity  being  as 
much  as  two  inches  and  its  lower  one  and  a  half  inch  behind 
the  respective  ends  of  the  coronal  suture.  The  coronal  suture 
does  not,  therefore,  correspond  to  the  boundary  between  the 
frontal  and  parietal  lobes  of  the  brain. 

The  parieto-occipital  fissure  is  situated  on  an  average  about 
07  to  08  inch  in  front  of  the  apex  of  the  lambdoidal  suture 
{Fig.  197,  PO). 

Contents  of  the  Respective  Areas. 

The  froibtal  area  is  occupied  by  the  frontal  lobe,  but  does  not  cover 
the  whole  of  it,  the  posterior  extremities  of  the  three  frontal  convolutions 
lying  behind  the  coronal  suture.  The  frontal  area  therefore  corresponds 
to  the  part  of  the  frontal  lobe  supplied  by  the  anterior  cerebral  artery, 
and  which  is  not  excitable  to  stimulation.  The  superior,  middle,  and  in- 
ferior frontal  areas  of  the  skull  correspond  respectively  to  the  superior, 
middle,  and  inferior  frontal  convolutions,  with  the  exception  of  their 
posterior  extremities. 

The  upper  antero-parietal  area  {Fig.  197,  SAP)  contains  the  upper 
two-thirds  of  the  ascending  frontal *(AP)  and  ascending  parietal  (S)  con- 
volution, and  the  posterior  extremities  of  the  superior  (I'Sin.)  and  middle 
frontal  (1  /yin.)  convolutions.  At  the  upper  posterior  angle  of  this  area 
part  of  the  postero-parietal  lobule  is  visible,  and  below  this,  part  of  the 
supra-marginal  lobule  may  appear. 

The  lower  antero-parietal  area  {Fig.  197,  lAP)  contains  the  lower  third 
of  the  ascending  parietal  (lin.)  and  ascending  frontal  (AP)  convolutions, 
and  the  posterior  extremities  (lin.)  of  the  inferior  frontal  convolution. 
A  small  portion  of  the  supra-marginal  gyrus  is  visible  at  the  upper 
posterior  angle  of  this  area,  and  below  it  a  small  portion  of  the  superior 
temporo-sphenoidal  convolution. 

The  upper  postero-parietal  area  {Fig.  197,  SPP)  contains  the  greater 
part  of  the  postero-parietal  lobule.  Below  it  lies  the  upper  portion  of  the 
angular  gyrus  (SPP),  and  part  of  the  supra-marginal  gyrus  (X  j.  Poste- 
riorly the  annectant  gyri  blend  with  the  occipital  lobe. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       427 

The  lower  postero-parietal  area  {Fig.  197,  IPP)  contains  part  of  the 
supra-marginal  gyrus,  and  behind  it  part  of  the  angular  gyrus,  and  below 
this  the  posterior  or  upper  ends  of  the  temporo-sphenoidal  convolutions. 

The  occipital  area  {Fig.  197,  0)  indicates  the  situation  of  the  occipital 
lobe,  but  is  not  co-extensive  with  it,  inasmuch  as  a  portion  extends  ante- 
riorly beyond  the  lambdoidal  suture  into  the  postero-parietal  area. 

The  squanioso-temporal  area  {Fig.  197,  Sq)  contains  the  greater  portion 
of  the  temporo-sphenoidal  convolutions,  but  the  superior  temporo- 
sphenoidal  convolution  ascends  into  the  lower  parietal  areas. 

Fig.  197. 


Fig.  197  (Turner).  Diagram  showing  the  Relations  of  the  Convolutions  of  the  Skull. 
E,  The  fissure  of  Rolando,  which  separates  the  frontal  from  the  parietal  lobe. 
PC,  The  parieto -occipital  fissure  between  the  parietal  and  occipital  lobes. 
SS,  The  fissure  of  Sylvius,  which  separates  the  temporo-sphenoidal  from  the 
frontal  and  parietal  lobes.  SF,  MF,  IF,  The  supero,  mid-,  and  infero-frontal 
subdivisions  of  the  frontal  area  of  the  skull ;  the  letters  are  placed  on  the 
superior,  middle  and  inferior  frontal  convolutions.  SA.P,  The  supero-antero- 
parietal  area  of  the  skull  :  S  is  placed  on  the  ascending  parietal  convolution, 
AP  on  the  ascending  frontal  convolution.  lAP,  The  infero-antero-parietal 
area  of  the  skull :  I  is  placed  on  the  ascending  parietal,  AP  on  the  ascending 
frontal  convolution.  SPP,  The  supero-postero-parietal  area  of  the  skull :  the 
letters  are  placed  on  the  angular  convolution.  IPP.  The  infero-postero-parietal 
area  of  the  skull  :  the  letters  are  placed  on  the  mid-temporo-sphenoidal  convo- 
lution. X ,  The  convolution  of  the  parietal  eminence,  or  supra-marginal  gyrus. 
0,  The  occipital  area  of  the  skull  :  the  letter  is  placed  on  the  mid-occipital 
convolution.  Sq,  The  squamoso-temporal  region  of  the  skull :  the  letters  are 
placed  on  the  mid-temporo-sphenoidal  convolution.  AS,  The  ali-sphenoid 
region  of  the  skull :  the  letters  are  placed  on  the  tip  of  the  supero-temporo- 
sphenoidal  convolution. 


428       ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

The  ali-sphenoidal  area  {Fig.  197,  AS)  contains  the  lower  or  anterior 
extremity  of  the  temporo-sphenoidal  lobe. 

The  central  lobe,  or  Island  of  Reil,  does  not  conae  to  the  surface,  but 
lies  deep  in  the  fissure  of  Sylvius,  and  is  concealed  by  the  convolutions 
which  form  the  margin  of  that  fissure  anteriorly.  It  lies  opposite  the 
upper  part  of  the  great  wing  of  the  sphenoid  and  its  line  of  articulation 
with  the  anterior  inferior  angle  of  the  parietal  and  the  squamous  part  of 
the  temporal. 

The  convolutions  situated  on  the  internal  aspect  of  the  hemisphere  are 
altogether  out  of  relation  to  the  surface  of  the  skull. 

The  deep-seated  position  and  direction  of  the  hippocampal  region  are 
superficially  indicated  by  the  convolutions  of  the  temporo-sphenoidal  lobes, 
contained  chiefly  in  the  inferior  postero-parietal,  squamoso-temporal,  and 
ali-sphenoidal  areas. 

#677.  INTERNAL  PARTS  OF  THE  CEREBRUM. 

The  anatomy  of  the  cerebrum  is  most  conveniently  studied 
by  successive  horizontal  sections. 

Centrum  Ovale. — A  horizontal  section  made  half  an  inch 
above  the  corpus  callosum  displays  the  white  matter  of  each 
hemisphere  surrounded  on  all  sides  by  the  grey  matter  of  the 
convolutions.  The  white  central  mass  in  each  hemisphere  was 
named  by  Vicq.  d'Azyr  the  centrum  ovale  minus.  A  section 
made  at  the  level  of  the  corpus  callosum  shows  that  the  white 
substance  of  that  part  is  continuous  with  the  central  white  sub- 
stance of  each  hemisphere.  The  large  white  medullary  mass 
thus  displayed  is  named  the  centrum  ovale  majus. 

The  Corpus  Callosum  connects  the  centres  of  the  two 
hemispheres,  and  it  approaches  nearer  their  anterior  than 
their  posterior  extremities.  It  terminates  behind  in  a  free 
rounded  end — the  splenium,  whilst  in  front  it  forms  a  knee- 
shaped  bend,  and  passes  downwards  and  backwards  as  far  as 
the  lamina  cinerea.  It  is  thicker  behind  than  in  front,  the 
middle  part  being  the  thinnest.  It  consists  of  bundles  of  nerve 
fibres,  almost  the  whole  of  which  pass  transversely  between  the 
two  hemispheres.  The  fibres  may  be  traced  into  the  white 
cores  and  grey  matter  of  the  convolutions,  and  apparently 
connect  corresponding  convolutions  in  the  opposite  hemispheres. 
A  few  fibres  run  longitudinally  on  the  surface  of  the  corpus 
callosum,  named  the  strice  longitudinales  or  nerves  of  Lancisi. 

Topography  of  the  Centrum  Ovale. — A  systematic  nomen- 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.       429 

clature  of  the  various  parts  of  the  centrum  ovale  has  been 
devised  by  Pitres.  His  system  consists  in  making  vertical 
sections  of  the  brain  at  definite  points,  and  naming  the  various 
parts  of  the  medullary  substance  exposed  in  each  section.  A 
vertical  section  of  the  hemisphere  at  right  angles  to  its  longi- 
tudinal axis  in  the  prse-frontal  region  gives  the  prce-frontal 
section  {Fig.  198).     The  next  section  is  made  two  centimetres 

Fig.  198. 


Fig.  198  (After  Pitres).  Prce-frontal  Bection.—l,  2,  3,  First,  second,  and  third 
frontal  convolutions.  4,  Orbital  convolutions.  5,  Convolutions  on  the  internal 
aspect  of  the  frontal  lobe.     6,  Prse-frontal  fasciculi  of  the  centrum  ovale. 

Fig.  199. 


Fig.  199  (After  Pitres).  Pedunculo-frontal  Section.— 1,  2,  3,  First,  second,  and  third 
frontal  convolutions.  4,  Anterior  extremity  of  the  insular  lobe.  5,  Posterior 
extremity  of  the  orbital  convolutions.  6,  Superior  pedunculo-frontal  fasciculus. 
7,  Middle  pedunculo-frontal  fasciculus.  8,  Inferior  pedunculo-frontal  fasciculus. 
9,  Orbital  fasciculus.  10,  Corpus  callosum.  11,  Caudate  nucleus.  12,  Internal 
capsule.     13,  Lenticular  nucleus. 


430       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


iu  front  of  the  fissure  of  Rolando  and  passes  through  the  bases 
of  the  three  frontal  convolutions,  and  is  named  the  pedunculo- 
frontal  section  {Fig.  199).  The  medullary  substance  in  this 
section  is  subdivided  into  a  superior,  middle,  and  inferior 
pedunculo-frontal  fasciculus,  corresponding  with  the  respective 
frontal  convolutions.  The  next  section  is  made  through  the 
ascending  frontal  convolution,  parallel  with  the  fissure  of 
Rolando,  and  is  named  the  frontal  section.  It  also  passes 
through  a  small  portion  of  the  sphenoidal  lobe.  The  medullary 
substance  of  this  section  is  also  subdivided  into  superior,  middle, 
and  inferior  frontal  fasciculi  {Fig.  200),     The  fourth  section 

Fi«.  200. 


Fig.  200  (After  Pitres).  Frontal  Section. — 1,  Ascending  frontal  convolution. 
2,  Insular  lobule.  3,  Sphenoidal  lobe.  4,  5,  6,  Superior,  middle,  and  inferior 
frontal  fasciculus.  7,  Sphenoidal  fasciculus.  8,  Corpus  callosum.  9,  Caudate 
nucleus.  10,  Optic  thalamus.  11,  Internal  capsule.  12,  Lenticular  nucleus. 
13,  External  capsule.    14,  Claustrum. 

is  carried  through  the  ascending  parietal  convolution,  and  is 
named  the  parietal  section.  It  is  subdivided  into  superior, 
middle,  and  inferior  parietal  fasciculi  {Fig.  201).  The  next 
is  the  pedunculo -parietal  section,  made  by  dividing  the  hemi- 
sphere three  centimetres  behind  the  fissure  of  Rolando,  and 
cutting  the  superior  and  inferior  parietal  lobules.     It  is  sub- 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 
Fig.  201. 


431 


Fig.  201  (After  Pitres).  Parietal  Section. — 1,  Ascending  parietal  convolution. 
2,  Insular  lobe.  3,  Sphenoidal  lobe.  4,  Superior  parietal  fasciculus.  5,  Middle 
parietal  fasciculus.  6,  Inferior  parietal  fasciculus.  7,  Sphenoidal  fasciculus. 
8,  9,  10,  11,  12,  13, 14,  as  in  the  preceding  figure. 


Fig.  202. 


Fig.  202  (After  Pitres),  Pedunculo-parietal  Section.— 1,  Superior  parietal  lobule. 
2,  Inferior  parietal  lobule.  3,  Sphenoidal  lobe.  4,  Superior  pedunculo-parietal 
fasciculus.  5,  Inferior  pedunculo-parietal  fasciculus.  6,  Sphenoidal  fasciculus. 
7,  Corpus  callosum.     8  and  10,  Caudate  nucleus.     9,  Optic  thalamus. 


432       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

divided   into   superior   and   inferior   pedunculo-parietal  and 
sphenoidal  fasciculi  (Fig.  202). 

The  last  is  the  occipital  section  (Fig.   203)  in  which  no 
separate  fasciculi  are  distinguished. 

Flu.  203. 


Fig.  203  (After  Pitres).  Occipital  Section.— 1,  Occipital  convolutiona.    2,  Occipital 
fasciculi  of  the  centrum  ovale. 

Lateral  Ventricles. — The  lateral  ventricle  is  divided  into  a 
central  space  or  body,  and  three  curved  prolongations  or  cornua. 
The  anterior  cornu  extends  forwards  and  outwards  into  the 
frontal  lobe,  the  posterior  curves  backwards,  outwards,  and  in- 
wards into  the  occipital  lobe,  and  the  descending  cornu  curves 
backwards,  outwards,  downwards,  forwards,  and  inwards,  behind 
and  below  the  optic  thalamus  into  the  temporo-sphenoidal  lobe. 

On  the  floor  of  the  central  space  may  be  seen  from  before 
backwards  the  caudate  nucleus,  and  to  its  inner  and  posterior 
part  a  small  portion  of  the  optic  thalamus,  whilst  between  the 
two  is  a  curved  flat  band,  the  tcenia  semicircularis.  The 
choroid  plexus  rests  on  the  upper  surface  of  the  optic  thalamus, 
and  immediately  internal  to  it  is  the  free  edge  of  the  fornix. 

The  anterior  end  of  the  caudate  nucleus  projects  into  the 
anterior  cornu,  while  the  posterior  cornu  has  an  elevation  on  its 
floor,  named  the  hippocampus  minor,  and  the  eminentia  col- 
lateralis  lies  between  the  posterior  and  descending  cornua.  The 
hippocampus  major  extends  along  the  floor  of  the  descending 
cornu,  and  terminates  below  in  a  nodular  end,  the  pes  hippo- 
campi. Along  its  inner  edge  is  a  narrow  white  band  prolonged 
from  the  posterior  pillar  of  the  fornix,  named  the  tcenia  hippo- 
campi.    If  the  taenia  be  drawn  aside  the  hippocampal  fissure 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       433 

is  exposed,  at  the  IJottom  of  which  the  grey  matter  of  the  gyrus 
hippocampi  may  be  seea  to  form  a  serrated  border,  named  the 
fascia  dentata.  The  choroid  plexus  enters  the  descending 
cornu  through  the  great  transverse  fissures  of  the  brain  between 
the  tsenia  hippocampi  and  optic  thalamus.  The  lateral  ven- 
tricle is  lined  by  cylindrical  epithelium,  which  rests  on  a  layer 
of  neuroglia,  and  is  in  many  parts  ciliated.  This  lining  is  con- 
tinuous with  that  of  the  third  ventricle  through  the  foramen  of 
Monro,  the  lining  of  the  latter  being  continuous  with  that  of  the 
fourth  ventricle  through  the  aqueduct  of  Sylvius.  A  little  fluid  • 
is  contained  in  the  cerebral  ventricles. 

Septum  Lwcidum. — If  the  corpus  callosum  be  divided  trans- 
versely about  its  middle,  and  the  two  halves  reflected  forwards 
and  backwards  respectively,  the  fornix  and  septwTn  lucidum 
are  exposed.  This  septum  extends  vertically  between  the  corpus 
callosum  above  and  the  fornix  below.  It  consists  of  two  layers 
of  grey  matter,  having  an  interval  between  them  containing 
fluid,  and  covered  by  an  epitheliated  membrane.  This  space 
is  the  Jifth  ventricle. 

The  fornix  is  an  arch-shaped  band  of  nerve  fibres  which  ex- 
tends in  the  antero-posterior  direction,  its  anterior  end  form- 
ing the  anterior  pillars,  its  posterior  the  posterior  pillars, 
and  its  body  the  summit  of  the  arch.  It  consists  of  lateral 
halves,  but  at  the  summit  of  the  arch  the  two  are  joined 
together  to  form  the  body.  The  anterior  pillars  are  separate 
from  one  another;  they  descend  in  front  of  the  third  ventricle 
to  the  base  of  the  cerebrum,  where  they  form  the  corpora 
alhicantia,  and  then  enter  the  substance  of  the  optic  thalamus. 
The  posterior  pillars  are  also  separate  ;  each  curves  downwards 
and  outwards  into  the  descending  cornu  of  .the  ventricle,  and 
forms  the  free  border  of  the  hippocampus  major,  which  is 
named  the  taenia  hippocampi. 

The  velum,  interpositum  is  a  fold  of  pia  mater  which  passes 
into  the  interior  of  the  hemispheres  through  the  great  trans- 
verse fissure.  It  is  triangular  in  shape,  the  base  is  in  a  line 
Avith  the  posterior  end  of  the  corpus  callosum,  the  lateral  mar- 
gins are  fringed  by  the  choroid  plexuses,  and  the  apex,  where 
the  choroid  plexuses  blend  with  each  other  through  the  foramen 
of  Monro,  lies  behind  the  anterior  pillars  of  the  fornix. 
CC 


484       ANATOMICAL  AND  PHYSIOLOGICAL   INTKODUCTION. 

The  choroid  plexuses  consist  of  highly  vascular  folds  of 
membrane,  and  the  epithelium  of  the  ventricles  is  continued 
over  their  surface.  These  plexuses  contain  the  small  choroidal 
arteries,  and  supply  the  corpora  striata,  the  optici  thalami,  and 
corpora  quadrigeraina,  the  blood  from  these  bodies  being  re- 
invned  hy  the  veins  of  Galen.  If  the  velum  interpositum  be 
raised  from  before  backwards,  the  optic  thalami,  third  ven- 
tricle, pineal  gland,  and  corpora  quadrigemina  are  exposed 
{Fig.  204). 

The  third  ventricle  is  a  cavity  situated  in  the  mesial  plane, 
between  the  optici  thalami ;  its  roof  is  formed  by  the  velum 
interpositum  and  the  body  of  the  fornix,  its  floor  by  the  pos- 
terior perforated  space  {"pons  Tarini),  the  corpora  albicantia, 
the  tuber  cinereum,  infundibulum,  and  optic  commissure ;  its 
anterior  boundary  by  the  anterior  commissure  and  laminae 
cinerea ;  its  posterior  boundary  by  the  corpora  quadrigemina 
and  posterior  commissure.  The  cavity  of  the  ventricle  is  small, 
and  it  is  crossed  at  its  middle  by  the  middle  or  soft  commis- 
sure, whieb  consists  of  grey  matter  and  connects  the  two  inner 
surfaces  of  the  optici  thalami  together,  K  the  anterior  pillars  of 
the  fornix  be  separated,  the  anterior  white  commissure  may  be 
seen  entering  the  lenticular  nuclei.  The  white  fibres  of  the 
posterior  commissure  pass  across  between  the  two  optic 
thalami  in  front  of  the  corpora  quadrigemina. 

BASAL    GANGLIA. 

§  678.  The  ganglia  of  the  base  of  the  cerebrum  are  the 
corpora  striata,  the  optici  thalami,  the  corpora  geniculata,  the 
corpora  quadrigemina,  and  the  locus  niger, 

(1).  The  corpora  striatum  is  situated  in  front  and  to  the 
outer  side  of  the  optic  thalami,  and  consists  of  two  masses  of 
grey  matter,  separated  from  each  other  by  bands  of  medullated 
fibres,  which  pass  from  below  upwards  through  its  substance. 
The  upper  mass  projects  into  the  lateral  ventricle,  and  is  called 
the  intra-ventricular  portion  or  caudate  nucleus. 

The  caudate  nucleus  consists  of  a  club-shaped  portion  directed  forwards, 
and  a  slender  tail-like  extremity  directed  backwards,  the  two  together 
forming  almost  a  complete  ring,  which  encircles  the  optic  thalamils  and 
internal  capsule,  like  a  loop  or  surcingle.    The  body  of  the  nucleus  grows 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       485 

smaller  as  it  extends  backwards  in  the  upper  part  of  the  ventricle,  and 
soon  runs  into  the  tail-like  prolongation  ;  when  the  latter  reaches  the 
posterior  end  of  the  optic  thalamus  it  curves  downwards  into  the  inferior 
horn  of  the  ventricle  and  runs  forward  to  its  anterior  extremity,  when  it 

Fig.  204. 


Fig,  204  (From  Henle's  Anatoiuie'. 

Ccl*,  Knee  of  the  corpus  callosum. 
Cs,  Corpus  striatum. 
Vsl,  Ventricle  of  the  septum  lucidum. 
Cf ,  Crura  of  the  fornix. 
Sf,  Taenia  semicircularis. 
Ts,  Anterior  tubercle  of  the  optic  tha- 
lamus. 


Basal  Ganglia  viewed  from  above. 

Com,  Cop,  The  middle  and  posterior 

commissures  respectively. 
Tfo,  Taenia  thalami  opt. 
Pv,  Pulvinar. 
Tho,  Optic  thalamus. 
Cn,  Pineal  gland. 
Pen,  Peduncles  of  the  pineal  gland. 


436       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

^  terminates  in  an  enlarged  extremity  almost  exactly  opposite  the  point 
where  it  started  in  the  anterior  horn.  The  head  of  the  caudate  nucleus 
is  continuous  with  the  lenticular  nucleus  and  with  the  grey  matter  of  the 
anterior  perforated  sjDace.  The  extremity  of  the  surcingle,  on  the  other 
hand,  is  connected  with  a  deposit  of  grey  matter  forming  the  anterior 
wall  of  the  inferior  horn  of  the  ventricle,  named  the  amygdala.  The 
tsenia  semicircularis  accompanies  the  concave  border  of  the  surcingle,  and 
runs  forwards  along  the  roof  of  the  inferior  horn  of  the  ventricle  to  its 
anterior  end,  and  there  terminates  in  the  amygdala  (Dalton).  In  a  vertical 
transverse  section  of  the  brain  through  the  optic  thalamus  the  superior 
portion  of  the  surcingle  is  visible  above  the  lenticular  nucleus  and  internal 
capsule,  while  the  inferior  portion  appears  as  aa  isolated  mass  of  grey 
matter  below  the  level  of  the  lenticular  nucleus  and  near  the  outer  part 
of  the  inferior  horn  of  the  ventricle. 

Fig.  205. 


Fig.  205  (After  Dalton).  Longitudinal  and  Vertical  Section  of  the  Right  Hemisphere, 
showing  the  Cavity  of  the  Lateral  Ventricle  and  the.  Caudate  Nucleus.  — ii.  Head 
of  the  caudate  nucleus.  S,  Surcingle.  V,  Ventricle.  A,  Amygdala.  1,  Parieto- 
occipital fissure.    2,  Calcarine  fissure. 

The  lower  extra-ventricular  portion,  or  lenticular  nucleus,  is  separated 
from  the  intra-ventricular  part  by  a  layer  of  white  substance  named  the 
internal  capsule,  while  it  is  separated  from  the  Island  of  Reil  by  a  layer  of 
white  substance  named  the  external  capsule,  and  a  grey  lamina  termed  the 
claustrum.  The  lenticular  nucleus,  as  its  name  implies,  is  of  the  form  of 
a  bi-convex  lens  on  horizontal  section,  but  on  a  vertical  section  through 
its  middle  it  appears  triangular,  the  apex  being  directed  inwards.  Two 
white  bands  which  run  parallel  to  the  outer  surface  of  the  nucleus  or  the 
external  capsule  divide  it  into  three  zones  named  from  within  outwards 
the  first,  second,  and  third  divisions  of  the  lenticular  nucleus. 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.       437 

(2)  The  optic  thalamus  is  of  an  oval  shape  and  rests  on  the 
crus  cerebri  of  the  same  side.  It  is  bounded  externally  by  the 
corpus  striatum  and  taenia  sejnicircularis.  The  upper  surface 
is  free  and  is  partly  seen  in  the  lateral  ventricle,  and  is  partly 
covered  by  the  fornix,  the  former  being  called  the  anterior 
tubercle  and  the  latter  the  posterior  tubercle  or  pulvinar. 

Fig.  206. 


Sra 


Am 


Fig.  206  (From  Henle's  Anatomie).  Vertical  Section  of  the  Brain  immediately 
behind  the  Anterior  Commissure  of  the  Third  Ventricle. — CcP,  Corpus  callosum  ; 
Vsl,  The  fifth  ventricle  ;  Ls,  Lamina  of  the  septum  lucidum  ;  Cs,  (Jaudate 
nucleus ;  B',  Internal  capsule ;  St,  Taenia  semicircularis ;  Nl,  Lenticular 
nucleus ;  Cls,  Claustrum  ;  In,  Island  of  Eeil ;  Cf,  Interior  pillars  of  the 
fornix ;  Cp,  External  capsule ;  Coa,  Anterior  commissure  of  the  third  ven- 
tricle ;  Coa',  Anterior  commissure  as  it  winds  back  beneath  the  lenticular 
nucleus  to  reach  the  convolutions  of  the  cortex  ;  Am,  Descending  horn  of  the 
lateral  ventricle ;  Sra,  Substantia  retic.  alba.  ;  II',  Optic  tract ;  To,  Tuber 
cLnereum. 


4sB8       ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 

The  posterior  surface  is  also  free  and  projects  into  the  descend- 
ing cornu  of  the  lateral  ventricle.  The  inner  surfaces  of  the 
two  thalami  form  the  lateral  walls  of  the  third  ventricle,  and 
are  connected  together  by  a  transverse  portion  which  forms  the 
middle  or  sofi  commissure  of  the  third  ventricle.  The  inner 
surface  is  lined  by  grey  matter  which,  according  to  Meynert,  is 
distinct  from  that  of  the  interior  of  the  thalamus,  and  is  pro- 
bably the  upward  continuation  of  the  central  grey  substance  of 
the  spinal  cord. 

The  internal  capsule  consists  of  a  thick  band  of  medullated 
fibres,  which  separates  the  lenticular  nucleus  on  the  one  hand 
from  the  caudate  nucleus  and  optic  thalamus  on  the  other.  On 
horizontal  section  the  internal  capsule  is  seen  to  consist  of  an 
anterior  and  posterior  division,  which  form  an  obtuse  angle 
with  one  another,  the  latter  being  called  the  knee  of  the 
internal  capsule.  The  anterior  division  lies  between  the 
anterior  and  internal  margin  of  the  lenticular  nucleus  and  the 
head  of  the  caudate  nucleus,  and  the  posterior  division  between 
the  posterior  and  internal  margin  of  the  lenticular  nucleus  and 
the  optic  thalamus ;  while  the  knee  of  the  capsule  is  directed 
inwards  towards  the  third  ventricle,  and  forms  by  its  projection 
a  partial  separation  between  the  caudate  nucleus  and  optic 
thalamus. 

The  external  capsule  consists,  as  already  mentioned,  of  a 
thin  band  of  white  substance  which  bounds  the  lenticular 
nucleus  externally  and  lies  between  it  and  the  claustrum. 

(3)  The  corpora  geniculata  consist  of  two  small  oblong  and 
flattened  eminences  connected  with  the  posterior  extremity  of 
the  optic  tract,  named  respectively  corpus  geniculatum  ex- 
ternum and  internum. 

(4)  The  locus  niger  is  a  dark  mass  of  grey  matter  which 
lies  between  the  crust  and  tegmentum  in  the  crus  cerebri.  It 
occupies  nearly  the  whole  diameter  of  the  crus  and  extends 
from  the  anterior  edge  of  the  pons  to  the  corpora  albicantia. 

The  pineal  body  or  gland  is  a  reddish  body,  enveloped  by 
the  velum  interpositum,  and  situated  upon  the  anterior  eleva- 
tions of  the  corpora  quadrigemina. 

The  pedu7ides  of  thepitual  body,  by  means  of  whicli  it  is  connected  with 
thereat  of  the  cerebrum^  pass  forwards,,  one  on  the  inner  side  of  each  optic 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       439 

thalamus,  to  join,  along  with  the  tteuia  aemicircularis,  the  anterior  pillar 
of  the  fornix  of  its  own  side. 

(5)  The  corpora  quadrigemi/na  or  optic  lobes  are  situated 
behind  and  between  the  optici  thalami,  and  rest  upon  the 
posterior  surface  of  the  crura  cerebri  These  bodies  are  divided 
into  four  eminences  by  a  longitudinal  and  transverse  fissure,  the 
anterior  pair  being  named  nates,  and  the  posterior  testes.  From 
each  testis  a  white  cord,  the  superior  peduncle  of  the  cere- 
bellum, passes  backwards  to  the  cerebellum,  while  the  valve 
of  Vieussens,  or  anterior  medullary  velum,  stretches  between 
the  pair  of  cerebellar  peduncles. 

The  aqueduct  of  Sylvius  is  a  narrow  canal  which  passes 
beneath  the  corpora  quadrigemina,  and  connects  the  third  with 
the  fourth  ventricle,  [t  is  lined  by  a  ciliated  cylindrical  epi- 
thelium, 

DISTEIBUTION  OF  THE  ARTERIES  OF  THE  BRAIN. 

§  679.  The  arteries  of  the  brain  are  derived  from  two  great 
trunks — the  vertebral  and  internal  carotid  arteries.  The  branches 
of  the  vertebrals  and  of  the  basilar  trunk  formed  by  their  union 
supply  the  posterior  and  lesser  portion  of  the  brain,  while  the 
terminal  branches  of  the  internal  carotid  arteries  supply  the 
anterior  and  greater  part  of  the  brain.  The  branches  distri- 
buted to  the  brain  from  the  vertebral  arteries  may  be  called 
the  posterior  or  vertebral,  and  those  derived  from  the  internal 
carotids  the  anterior  or  carotid  arterial  system. 

The  posterior  cerebral  arteries  are  the  terminal  branches  of 
the  basilar  trunk.  Each  artery  winds  round  the  crus  cerebri  to 
reach  the  occipital  lobe,  and  gives  off  a  number  of  twigs — the 
posterior  median  group  (Fig.  211,  2) — which  pierce  the  pos- 
terior perforated  space,  and  supply  the  internal  surface  of  the 
optic  thalamus,  and  the  walls  of  the  third  ventricle. 

Branches. — A  choroid  branch  is  given  off  to  the  velum  interpositum, 
and  small  twigs  pass  into  the  substance  of  the  crus  cerebri  as  the  vessel 
winds  round  it.  A  number  of  small  branches,  the  postero-lateral  group 
(Fig.  211, 4),  enter  the  base  of  the  brain  behind  the  posterior  border  of  the 
crus  cerebri,  and  pass  into  the  optic  thalamus  and  corpora  quadrigemina. 

The  cortical  branches  are  three  in  number  ;  the  first,  or  anterior  tem- 
poral artery,  being  distributed  to  the  anterior  part  of  the  uncinate  gyrus 


440       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


and  its  vicinity  ;  the  second,  or  posterior  temporal  artery,  to  the  posterior 
part  of  the  uncinate  gyrus  and  the  lower  part  of  the  temporo-sphenoidal 
lobe  ;  and  the  third,  or  occipital  artery,  to  the  inner  and  outer  surfaces  of 
the  occipital  lobe. 

Fig.  207. 


Fig.  207  (After  Ecker  and  Duret).     View  of  the  Brain  from  below. 

DISTRIBUTION  OF  VESSELS. 

The  region  bounded  by  the  line  ( )  represents  the  territory  over  which  the 

Internal  and  Inferior  Frontal  Branches  of  the  Anterior  Cerebral  Artery  are 
distributed. 

The  regions  bounded  by  the  line  ( )  represent  the  territories  over 

which  the  branches  of  the  Posterior  Cerebral  Artery  are  distributed. 
I.  Is  the  region  of  the  Anterior  Temporal  Artery, 
II.  ,,  ,,        Posterior  Temporal  Artery. 

III.  ,,  ,,        Occipital  Artery, 

The  internal  carotid  artery  reaches  the  base  of  the  brain 
close  to  the  outer  side  of  the  optic  commissure,  and  immediately 
breaks  up  into  two  branches — the  anterior  and  middle  cerebral 
arteries. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       441 

The  anterior  cerebral  artery  {Fig.  211,  C  A)  runs  forwards 
in  the  longitudinal  fissure,  and,  turning  round  the  corpus 
callosum,  is  distributed  to  the  anterior  part  of  the  cerebrum. 
The  arteries  of  the  two  sides  are  united  at  their  commencement 
by  a  short  transverse  branch,  the  anterior  coTiimunicating 
artery. 

Fig.  208. 


Fig.  208  (After  Ecker  and  Duret).    Inner  Surface  of  Bight  Hemisphere. 

DISTRIBUTION  OF  VESSELS. 

The  regions  bounded  by  the  line  ( )  represent  the  territories  over  which  the 

branches  of  the  Anterior  Cerebral  Artery  are  distributed. 

I.  Is  the  territory  of  the  Interior  and  Anterior  Frontal  Artery. 
II.  ,,  ,,  Internal  and  Middle        ,,  ,, 

III.  ,,  ,,  Internal  and  Posterior     ,,  ,, 

The  regions  bounded  by  the  line  ( )  represent  the  territories  over 

which  the  branches  of  the  Posterior  Cerebral  Artery  are  distributed. 
II.  Is  the  territory  of  the  Posterior  Temporal  Artery. 
III.  ,,  ,,  Occipital  Artery. 


Branches. — The  anterior  mediavt,  group  {Fig.  211,  1)  are  given  off  from 
the  anterior  communicating  and  the  commencement  of  the  anterior  cere- 
bral arteries ;  they  supply  the  anterior  part  of  the  head  of  the  caudate 
nucleus.  The  cortical  branches  are  four  in  number — the  first  being  dis- 
tributed to  the  two  internal  orbital  convolutions ;  the  second  to  the  ante- 
rior extremity  of  the  marginal  convolution,  and  to  the  superior  and  anterior 
portions  of  the  middle  frontal  convolutions  on  the  outer  surface  ;  the 


442       ANATOMICAL  AND   PHYSIOLOGICAL   INTEODUCTION, 

third  to  the  inner  surface  of  the  hemisphere  as  far  as  the  extremity  of  the 
calloso-marginal  fissure  ;  and  the  fourth  to  the  quadrate  lobule,  the  last 
supplying  a  branch  to  the  corpus  callosum. 

The  middle  cerebral  or  Sylvian  artery  (Figs.  210,  211,  S) 
runs  in  the  fissure  of  Sylvius,  and  is  the  largest  and  most 
important  branch  of  the  internal  carotid  artery.  It  gives  small 
branches — the  antero-lateral  group  {Fig.  211,  8) — which  pierce 
the  anterior  perforated  space,  and  supply  the  corpus  striatum 
and  anterior  part  of  the  optic  thalamus. 

Fig.  209. 


Fig.  209  (After  Ecker  and  Duret).     Outer  Surface  of  the  Left  Hemisphere. 

DISTRIBUTION  OP  VESSELS. 

The  region  bounded  by  the  line  ( )  represents  the  territory  over  which 

branches  of  the  Anterior  Cerebral  Artery  are  distributed. 

The  anterior  regions  bounded  by  the  line  ( )  represent  the  territories 

over  which  branches  of  the  Middle  Cerebral  Artery  are  distributed. 
I.  Is  the  region  of  the  External  and  Inferior  Frontal  Artery. 
II,  ,,  ,,        Anterior  Parietal  Artery. 

III.  „  ,,        Posterior  Parietal  Artery, 

IV.  ,,  ,,        Parieto-sphenoidal  Artery. 

The  posterior  and  inferior  region   bounded    by  the  line    (— • — .-— ) 

represents  the  territory  over  which  branches  of  the  Posterior  Cerebral 
Artery  are  distributed. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       443 

Branches. — A  choroid  branch  is  given  oflf  either  by  the  middle  cerebral 
or  internal  carotid  arteries,  which  winds  round  the  crus  cerebri  to  reach 
the  choroid  plexus  of  the  lateral  ventricle.  The  main  trunk  divides  into 
four  branches.    The  first,  or  inferior  frontal  branch  (Fig.  210,  1),  is  limited 

Fig.  210. 


Fig.  210.  Diagram  Showing  the  Area  of  Distribution  of  the  Middle  Cerebral  Artery. 
S,  Sylvian  or  middle  cerebral  artery ;  P,  Perforating  branches ;  1,  Inferior 
frontal  branch ;  2,  Ascending  frontal  branch ;  3,  Ascending  parietal  branch ; 
4  and  5,  Parieto-sphenoidal  and  sphenoidal  branches;  A,  Ascending  frontal 
convolution;  15,  Ascending  parietal  convolution;  Fj,  Fj,  F3,  First,  second, 
and  third  frontal  convolutions;  Pj,  P2,  P3,  First,  second,  and  third  parietal 
convolutions;  T,,  T2,  T3,  First,  second,  and  third  temporo-sphenoidal  con- 
volutions ;  OL,  Occipital  lobe. 


in  its  distribution  to  the  outer  part  of  the  orbital  surface  and  the  adjacent 
inferior  or  third  frontal  convolution.  The  second,  or  ascending  frontal 
branch  {Fig.  210,  2),  supplies  the  posterior  part  of  the  middle  frontal  and 
the  chief  part  of  the  ascending  frontal  convolutions.  The  third,  or 
ascending  parietal  artery  {Fig  210,  3),  passes  into  the  fissure  of  Rolando,  and 
supplies  the  rest  of  the  ascending  frontal  and  the  ascending  parietal  con- 
volutions as  well  as  the  anterior  part  of  the  superior  parietal  lobule.  The 
fourth  and  fifth,  or  parieto-sphenoidal  and  sphenoidal  branches  {Fig.  210, 
4  a,ud  5;,  supply  the  inferior  parietal  lobule  and  the  superior  temporo- 
sphenoidal  convolutions. 

The  'posterior  communicating  artery  is  a  long  and  slender 
vessel  which  connects  the  internal  carotid  with  the  posterior 
cerebral  arteries. 


444       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

The  circle  of  Willis  is  formed  by  the  union  of  the  anterior 
and  posterior  arterial  cerebral  systems  by  means  of  the  posterior 
communicating  arteries.  The  free  anastomosis  which  is  thus 
formed  enables  the  circulation  of  blood  in  the  brain  to  be  carried 
on  when  one  of  the  main  trunks  is  obstructed. 

Fig.  211. 


Fig.  211  (After  Charcot).  Diagram  of  the  Distribution  of  the  Vessels  at  the  base  of 
the  Cerebrum. — CA,  Anterior  cerebral  artery.  S,  S,  Sylvian  arteries.  V,  V, 
Vertebral  arteries.     B,  Basilar.      CP,  CP,  Posterior  cerebral  arteries.      1,  2, 

3,  3,  4,  4,  G-roups  of  nutritive  arteries.      The  line limits  the  ganglionic 

vascular  area. 


The  following  parts  of  the  encephalon  are  situated  within 
this  vascular  area :  the  optic  commissure,  laminae  cinerea,  in- 
fundibulum  and  tuber  cinereum,  corpora  albicantia,  posterior 
perforated  spot  with  part  of  the  crura  cerebri,  and  the  origin  of 
the  third  pair  of  nerves. 

Cortical  System  of  Arteries. — The  arteries  which  supply  the  cortex  of 
the  brain  ramify  in  the  pia  mater  and  are  distributed  to  the  grey  matter 
of  the  convolutions  and  subjacent  white  matter.     The  terminal  ramifica- 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       445 

tions  of  the  Sylvian  artery  may  be  taken  as  the  type  of  the  distribution  of 
the  cortical  system  of  arteries.  The  main  artery  divides  into  the  five 
secondary  branches  which  have  already  been  described,  and  each  of  these 
again  subdivides  into  two  or  three  tertiary  branches.  Each  tertiary  branch 
(Fig.  212,  A)  of  the  main  artery  subdivides  into  primary  {Fkj.  212,  B), 
and  secondary  twigs  {Fig.  212,  C,  C),  and  these  form  in  the  pia  mater  a 
vascular  ramification  from  which  the  nutritive  arteries  of  the  brain  are 
derived.  Duret  asserts  that  the  tertiary  branches  of  the  main  artery 
sometimes  anastomose  with  similar  branches  of  the  neighbouring  vascular 
territories,  but  the  primary  and  secondary  twigs  of  these  branches  do  not 
anastomose  amongst  themselves. 

Fig.  212. 


Fig.  212  (After  Duret).— A,  Tertiary  branch  of  the  main  artery.  B,  Primary 
twigs.  C,  C,  Secondary  twigs.  2,  2,  Cortical  arteries.  3,  Network  of  cortical 
arteries  in  the  cerebral  tissues. 


Nutritive  Arteries  of  the  Brain. 

The  nutritive  arteries  are  derived,  not  only  from  the  extremities  of  the 
primary  and  secondary  twigs,  but  a  large  number  issue  from  the  sides  of 
these  twigs,  as  well  as  from  the  sides  of  the  tertiary  branches  of  the  main 
artery  {Fig.  212,  I,  2).  The  nutritive  arteries  are  of  two  kinds — (a)  the 
lotig  or  medullary,  and  (6)  the  short  or  cortical  arteries. 

(a)  The  medullary  arteries  pass  into  the  substance  of  the  centrum 
ovale  for  a  distance  of  three  or  four  centimetres.  They  do  not  commu- 
nicate with  each  other  in  their  course  except  by  fine  capillaries,  and  con- 
sequently constitute  so  many  small  independent  vascular  territories.  The 
terminations  of  these  vessels  approach  the  upward  continuation  of  the  gang- 


446       ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

lionic  system  of  vessels,  but  the  two  systems  do  not  appear  to  anastomose 
with  one  another.  In  a  section  of  a  convolution,  twelve  or  fifteen  medul- 
lary arteries  may  appear  ;  three  or  four  of  these  pass  into  the  free  surface 
of  the  convolution  {Fig.  213,  1),  and  pursue  a  vertical  course;  those  which 
enter  the  sides  of  the  convolution  pursue  an  oblique  course  through  it, 
while  those  which  pass  into  the  bottom  of  the  fissure  again  become  vertical. 

Fia.  213. 


Fig.  213  (After  Buret).—!,  1,  Medullary  arteries.  1',  Group  of  medullary  arteriea 
in  the  fissure  between  two  neighbouring  convolutions,  1",  Arteries  of  the  system 
of  arcuate  fibres.  2,  2,  2,  Arteries  of  the  grey  substance  of  the  cortex,  a,  A 
large  meshed  capillary  network  situated  under  the  pia  mater.  6,  A  smaller 
meshed  capillary  network  situated  in  the  tniddle  layers  of  the  cortex,  c,  Some- 
what larger  network  in  the  internal  layers  adjoining  the  white  substance. 
d,  Capillary  network  of  the  white  substance. 


(6)  The  coHical  nutritive  arUnes  arise  from  the  vascular  network  of 
the  pia  mater  in  the  same  way  as  the  long  arteries,  but  the  former  are 
thinner  than  the  latter  and  pursue  a  shorter  course.  Some  of  these 
vessels  pass  through  the  whole  thickness  of  the  grey  substance,  and  give 
small  capillaries  to  the  centrum  ovale,  while  others  terminate  in  the  sub- 
stance of  the  cortex.  The  Vascular  network  in  the  convolutions  possesses 
the  following  characteristics  : — In  the  .first  layer,  about  one-half  milli- 
metre in  thickness,  the  meshes  of  the  network  aie  large  {Fig.  213,  to) ;  in 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION.       447 

the  second,  correspondug  to  two  layers  of  ganglionic  cells,  a  very  close 
and  fine  vascular  network  is  formed  {Fig.  213,  b) ;  iu  the  third,  corre- 
sponding to  the  internal  layers  of  the  cortex,  a  larger  and  coarser  vascular 
network  exists  {Fig.  213,  c);  and  in  the  fourth  layer,  or  medullary  sub- 
stance, a  still  larger'  and  coarser  vascular  network  is  observed. 

The  Central  or  Oanglionic  System  of  Arteries. 
These  arteries  consist  of  small  branches  which  are  given  off  from  the 
trunks  of  the  chief  cerebral  vessels ;  they  pierce  the  base  of  the  brain 
perpendicularly  to  reach  the  substance  of  the  basal  ganglia.  These 
arteries  form  six  main  groups,  which  may  be  named  the  anterior  and 
posterior  median  {Fig.  211,  1  and  2),  the  right  and  left  antero-lateral 
(Fig.  211,  3,  3),  and  the  right  and  left  postero-lateral  {Fig.  211,  4, 4)  groups. 
An  imaginary  line  passing  round  the  circle  of  Willis,  at  a  distance  of  two 
centimetres  external  to  it,  would  completely  surround  all  these  vessels, 
and  the  area  so  limited  may  therefore  be  called  the  ganglionic  vascular 
area  (Charcot).  All  these  vessels  are  terminal  arteries.  Some  of  these 
vessels  are^  of  sufficient  importance,  owing  to  their  liability  to  rupture,  as  to 
deserve  special  description.  The  vessels  derived  from  the  middle  cerebral 
artery — the  antero-lateral  group— after  piercing  the  anterior  perforated 

Fig.  214. 


Fig.  214  (From  Buret).  Transverse  Section  of  the  Cerebral  hemispheres,  about  1  cm. 
behind  the  Optic  Commissure. 

Akteeies  op  the  Corpus  Striatum.  —  Gh,  Chiasraa ;  B,  Section  of  the 
optic  tract ;  L,  Lenticular  nucleus  ;  /,  Internal  capsule  ;  C,  Caudate  nucleus  ; 
JE,  External  capsule  ;  T,  Claustrum  ;  R,  Island  of  Reil ;  V,  V,  Section  of  the 
lateral  ventricle;  P, -P,  Anterior  pillars  of  the  fornix;  0,  trrey  substance  of 
the  third  ventricle. 

Vascular  Areas.— I,  Anterior  cerebral  artery ;  II,  Middle  cerebral 
artery  ;  III,  Posterior  cerebral  artery. — 1,  Internal  carotid  artery ;  2,  Sylvian 
artery ;  3,  Anterior  cerebral  artery ;  4,  4,  External  arteries  of  the  corpiis 
striatum  (lenticulo-striate  artery) ;  5, 5,  Internal  arteries  of  the  corpus  striatum 
(lenticular  arteries).    The  opto-striate  artery  is  not  represented  in  the  figure. 


448       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

space,  ascend  vertically  to  supply  the  corpus  striatum,  the  internal  capsule, 
and  a  portion  of  the  optic  thalamus.  The  following  branches  may  be 
distinguished  : — 

(a)  Lenticular  branches  consist  of  two  or  three  small  twigs,  which 
ascend  vertically  and  enter  the  substance  of  the  lenticular  nucleus,  and 
are  distributed  to  its  two  inner  divisions  and  the  adjoining  portion  of  the 
caudate  nucleus  {Fig.  214,  5). 

(h)  The  lenticulo-striate  branch  is  much  larger  than  either  of  the  pre- 
ceding arteries.  It  ascends  along  the  external  surface  of  the  outer  division 
of  the  lenticular  nucleus,  traverses  the  superior  part  of  the  internal  cap- 
sule, and  then  passes  from  behind  forwards  into  the  substance  of  the 
caudate  nucleus.  It  gives  branches  to  the  outer  division  of  the  lenticular 
nucleus,  the  internal  capsules,  and  the  caudate  nucleus  {Fig.  214,  4). 

{c)  The  lenticulo-optic  branch  passes,  like  the  lenticulo-striate  artery, 
along  the  external  surface  of  the  outer  division  of  the  internal  capsule, 
passes  through  the  posterior  part  of  the  internal  ■  capsule,  and  terminates 
in  the  anterior  and  external  part  of  the  optic  thalamus.  The  anterior 
median  group  of  vessels  derived  from  the  anterior  cerebral  and  anterior 
communicating  arteries  are  small  arteries  ;  they  supply  the  anterior  part 
of  the  caudate  nucleus,  and  derive  their  chief  importance  from  the  fact 
that  hsemorrhage  from  themmay  rupture  into  the  ventricles  and  thus  cause 
rapid  death. 

The  posterior  cerebral  artery  gives  rise  to  two  branches,  which  deserve 
special  mention,  (i.)  HhQ  posterior  internal  artery  of  the  optic  thalamus, 
which  is  derived  from  the  artery  near  its  point  of  origin  from  the  basilar, 
and  is  distributed  to  the  internal  surface  of  the  optic  thalamus.  Hsemor- 
rhage  from  this  vessel  often  finds  its  way  into  the  ventricular  cavity, 
(ii.)  The  posterior  external  artery  of  the  optic  thalamus  is  derived  from  the 
posterior  cerebral  artery  after  it  has  wound  round  the  peduncle.  It  passes 
upwards  in  the  crus  to  the  posterior  part  of  the  optic  thalamus,  where  it 
terminates.     It  supplies  the  external  geniculate  bodies. 

INTERNAL  STRUCTURE  OF  THE  CEREBRUM. 

§  680.  The  cerebrum  is  made  up  of  (1)  grey  and  (2)  white 
matter. 

(1)  The  ^re^/ mazier  is  disposed  in  three  great  groups  :  (a)  the 
grey  matter  which  forms  the  central  end  of  the  cerebro-spinal 
tube ;  (6)  the  grey  matter  of  the  basal  ganglia ;  (c)  the  grey 
matter  of  the  cortex  of  the  hemisphere. 

{a)  The  grey  matter  which  forms  the  central  end  of  the 
cerebro-spinal  tube  has  already  been  described  up  to  the  level 
of  the  opening  of  the  aqueduct  of  Sylvius  into  the  third  ven- 
tricle, and  the  grey  matter  which  surrounds  the  third  ventricle 


ANATOMICAL  AND  PHYSIOLOGICAL   INTKODUCTION.       449 

may  be  regarded  as  the  upward  continuation  of  the  central 
tube.  The  grey  matter  of  the  third  ventricle  consists  of  a 
well-defined  layer  covering  the  inner  wall  of  each  optic 
thalamus  and  the  masses  situated  at  the  base  of  the  brain 
between  and  in  front  of  the  crura  cerebri ;  viz.,  the  posterior 
perforated  space  (pons  Tarinij,  tuber  einereum,  lamina  cinerea, 
infundibulum,  and  part  of  the  pituitary  body, 

(6)  The  basal  ganglia  consist  of  the  locus  niger,  red  nucleus 
of  the  tegmentum,  corpora  quadrigemina,  the  corpora  genicu- 
lata,  the  optic  thalami,  and  corpora  striata. 

The  locus  niger  lies  between  the  crus  and  tegmentum,  and 
extends  the  whole  diameter  of  the  crus,  and  from  the  anterior 
edge  of  the  pons  to  the  corpora  albicantia.  It  consists  of  nerve 
cells  of  various  forms  containing  much  dark  pigment. 

The  red  nucleus  of  the  tegmentum  is  a  round,  reddish-grey 
centre,  in  structure  somewhat  similar  to  the  olivary  body  of  the 
medulla  oblongata. 

The  corpora  quadrigemina  consist  of  grey  and  white  matter, 
the  former  being  continuous  in  front  with  the  grey  matter  of 
the  optic  thalamus,  and  behind  with  that  of  the  pons,  and  by 
means  of  the  nucleus  of  the  roof  of  the  fourth  ventricle  with 
the  corpus  dentatum  of  the  cerebellum. 

The  Corpora  Oeniculata. — The  external  geniculate  body  is 
densely  filled  with  large  branching  and  fusiform  cells,  and 
the  fibres  of  the  outer  portion  of  the  optic  tract  pass  through  it. 
The  internal  geniculate  body  contains  numerous  small  nerve 
cells  similar  to  those  of  the  corpora  quadrigemina. 

The  optic  thalamus  is  composed  of  interlacing  fibres  mingled 
with  grey  matter.  The  nerve  cells  in  the  grey  matter  are  both 
multipolar  and  fusiform. 

The  m,iddle  or  grey  commissure,  connecting  the  two  thalami, 
consists  of  small  cells  containing  yellow  pigment. 

The  corpus  striatum  is  arranged  in  two  chief  masses,  named 
respectively  the  caudate  and  lenticular  nuclei.  The  caudate 
nucleus  is  connected  below  with  the  lamina  cinerea,  the  anterior 
perforated  space,  and  that  part  of  the  grey  matter  of  the  optic 
thalamus  which  is  seen  in  the  third  ventricle.  It  contains  large 
and  small  nerve  cells,  both  possessing  many  branched  processes. 
DD 


450       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

No  axis-cylinder  process  has  been  observed  springing  from  the 
cells  of  the  caudate  nucleus. 

The  lenticular  nucleus  is  continuous  below  with  the  caudate 
nucleus,  and  with  the  grey  matter  of  the  anterior  perforated 
space.  The  two  innermost  zones  contain  numerous  large 
branching  nerve  cells  with  yellow  pigment.  The  cells  are 
smaller  in  the  outer  division  of  the  nucleus. 

The  claustrwm  is  made  up  of  fusiform  and  bipolar  cells, 
somewhat  resembling  the  cells  of  the  vesicular  column  of  Clarke 
on  the  one  hand,  and  those  of  the  fifth  layer  of  the  cortex  on 
the  other. 

The  amygdaloid  nucleus  is  a  small,  round  mass  of  grey  matter, 
connected  with  the  inferior  part  of  the  claustrum.  It  lies  in 
front  of  the  anterior  extremity  of  the  descending  horn  of  the 
lateral  ventricle,  and  is  composed  of  fusiform  cells  similar  to 
those  of  the  claustrum. 

(c)  The  Grey  Matter  of  the  Cortex. — When  a  convolution  is 
divided  vertically  the  grey  matter  is  seen  to  be  confined  to 
the  surface  and  to  enclose  a  white  core.  The  cortical  substance 
consists  of  cells  and  fibres  embedded  in  a  matrix  similar  to  the 
neuroglia  of  the  spinal  cord. 

The  cells  are  of  various  forms,  the  most  usual  forms  being 
spherical,  stellate,  pyramidal,  and  fusiform.  The  fibres  radiate 
into  the  grey  cortex  from  the  white  centre  of  each  convolution, 
their  course  being  vertical  to  the  free  surface  of  the  convolution. 
They  are  arranged  in  bundles  as  they  pass  through  the  grey 
substance,  and  this  gives  to  the  nerve  cells  a  columnar  arrange- 
ment. The  radiating  fibres  are  wanting  in  the  sulci  between 
the  convolutions,  but  the  internal  layer  of  the  grey  substance 
of  the  cortex  generally  contains  fibres  which  pursue  an  arciform 
course  and  connect  adjacent  convolutions.  Fibres  pass  in  all 
directions  through  the  grey  substance  connecting  its  several 
layers,  and  forming  a  dense  network,  like  that  of  Gerlach  in 
the  spinal  cord. 

Layers  of  the  Cortex. — The  cortex  of  the  cerebrum  is  divided 
into  several  layers,  each  of  which  possesses  a  definite  histological 
character.  The  most  commonly  distributed  form  of  structure 
is  what  Meynert  has  called  the  "five  laminated  type."  The 
external   layer   consists   of  neuroglia  and  a  layer  of  delicate 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       451 


nerve  tubes,  along  with  a  few 
scattered  small  nerve  cells 
which  are  destitute  of  pro- 
cesses. The  next  layer  is  com- 
posed of  small  angular  or 
pyramidal  nerve  cells  with 
branching  processes.  The 
third  layer  contains  large  and 
small  pyramidal  cells  with 
branching  processes,  arranged 
with  their  pointed  extremi- 
ties towards  the  surface  of 
the  convolutions,  and  sepa- 
rated into  groups  by  bundles 
of  the  radiating  fibres.  In  the 
innermost  portion  of  this  layer 
the  pyramidal  cells  are  larger 
than  in  the  remaining  portions, 
and  it  has  therefore  been  de- 
scribed as  a  separate  layer  by 
Dr.  Lockhart  Clarke.  In  the 
cortex  of  the  occipital  lobe  the 
deeper  cells  of  the  third  layer 
are  pyramidal  in  form,  with 
their  bases  turned  inwards 
towards  the  medullary  sub- 
stance, but  their  basal  pro- 
cesses are  directed  laterally  so 
as  to  connect  adjacent  cells, 
and  none  of  them  appear  to  be 
directed  inwards  to  connect 
the  cells  with  the  fibres  of  the 
medullary  substance.  In  the 
anterior  portion  of  the  frontal 
convolutions  the  disposition  of 
these  cells  is  somewhat  similar, 
but  a  distinct  basal  process  has 
occasionally  been  observed, 
which  is  directed  towards  the 


Fig.  215. 


mm 


liijiidiiig 


Fig.  215  (After  Meynert).  Transparent 
Section  of  a  Furroiv  of  the  Third  Cere- 
bral Convolution  of  Man.  Magnified 
100  decimeters. — 1,  Layer  of  the  scat- 
tered small  cortical  corpuscles ;  2, 
Layer  of  close-set,  small  pyramidal 
corpuscles ;  3,  Layer  of  large  pyra- 
midal cortical  corpuscles  (formation 
of  the  comu  Ammonis) ;  4,  Layer  of 
small,  close-set,  irregular-shaped  cor- 
tical corpuscles  (granule -like  forma- 
tion) ;  5,  Layer  of  fusiform  cortical 
corpuscles  (claustral  formation) ;  m, 
the  medullary  lamina. 


452       ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

medullary  substance  of  the  convolution,  and  which  afterwards 
becomes  continuous  with  one  of  the  fibres  of  the  centrum 
ovale. 

In  the  central  convolutions  of  the  brain  Betz  and  Mezier- 
jewski  have  discovered  cells  which  are  two  or  three  times  the 
size  of  the  pyramidal  cells  of  the  other  regions  of  the  cortex, 
and  they  have   consequently  named    them  giant-cells.      In 


Fig.  216. 


Fig.  216.    Pyramidal  Giant-Cell.  —  n.  Nucleus ;    a,  a,  a.  Branched  processes ; 
c,  Unbranched  basal  process. 

addition  to  the  branched  protoplasmic  processes  {Fig.  216,  a,  a) 
which  connect  neighbouring  cells  with  one  another,  these  cells 
possess  a  distinct  axis-cylinder  process  {Fig.  216,  c).  The  latter 
is  always  unbranched,  and  after  becoming  surrounded  by  a 
medullary  sheath  it  forms  the  axis  cylinder  of  a  nerve  fibre  of 
the  centrum  ovale.  Giant-cells  have  been  observed  in  the  para- 
central lobule  and  in  a  portion  of  the  postero-parietal,  as  well  as 
in  the  ascending  frontal  and  parietal  convolutions,  and  posterior 
extremities  of  the  three  frontal  gyri.     These  cells  are  disposed 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       453 

in  groups,  and  correspond  in  position  to  the  motor  centres  of 
physiologists.  The  giant-cells  vary  greatly  in  size,  the  largest 
being  found,  as  we  have  already  seen,  in  the  paracentral  lobule, 
which  may  be  regarded  as  the  upper  extremity  of  the  ascending 
frontal  and  parietal  convolutions.  Large  pyramidal  cells  are 
also  found  in  the  upper  part  of  the  ascending  frontal  convolu- 
tions, but  Dr.  Bevan  Lewis  has  found  that  they  diminish  in  size 
from  the  upper  extremity  until  at  the  lower  extremity  they 
are  but  half  the  size.  The  pyramidal  cells  of  the  posterior 
extremities  of  the  frontal  convolutions  are  on  the  whole  smaller 
than  those  of  the  ascending  frontal,  and  the  cells  also  diminish 
from  above  downwards,  those  in  Broca's  convolution  being  the 
smallest. 

The  fourth  layer  consists  of  closely-set  angular  corpuscles 
with  fine  processes,  placed  irregularly  and  not  distinctly  sepa- 
rated into  groups. 

The  fifth  layer  consists  of  medium-sized,  fusiform,  and 
bipolar  cells.  The  long  diameters  of  these  cells  run  parallel 
to  the  layers  of  the  cortex,  and  are  associated  with  the  system 
of  fibres  which  connects  different  convolutions  of  the  same 
hemisphere  with  one  another. 

(2)  The  white  matter  of  the  cerebrum  consists  of  (a)  trans- 
verse or  commissural  fibres  ;  (6)  longitudinal  or  collateral  fibres ; 
and  (c)  ascending  or  peduncular  fibres. 

(a)  The  transverse  or  commissural  fibres  consist  of  the 
following : — 

(i.)  The  transverse  Jibres  of  the  corpus  ccdlosum  pass  transversely  from 
one  side  to  the  other,  and  connect  corresponding  convolutions  in  the 
hemispheres.  These  fibres  lie  on  a  plane  superior  to  those  of  the  corona 
radiata,  and  consequently  the  two  systems  of  fibres  interlace  on  their  way 
to  the  convolutions. 

(ii.)  The  Jibres  of  the  anterior  commissure  wind  backwards  through  the 
lenticular  nuclei  to  reach  the  convolutions  around  the  Sylvian  fissure. 

(iii.)  The  fibres  of  the  posterior  commissure  run  through  the  optic  thalami. 

(6)  The  longitudinal  ox  collateral  By^iQm.  of  fibres  are  the 
following  : — 

(i.)  Arcuate  fibres  or  fibrce  proprice,  which  are  situated  immediately 
beneath  the  inner  surface  of  the  cortex,  and  connect  together  the  grey 
matter  of  adjacent  convolutions. 


454)       ANATOMICAL   AND  PHYSIOLOGICAL   INTEODUCTION. 

(ii.)  Fibres  of  the  gyrus  forniccttus  take  a  longitudinal  course  imme- 
diately above  the  corpus  callosum  and  form  the  white  matter  of  that 
convolution.  In  front  they  bend  round  the  corpus  callosum,  and  become 
connected  with  the  anterior  perforated  space.  Behind  they  turn  round 
the  back  of  the  same  body,  and  are  said  to  pass  forwards  to  reach  the 
anterior  perforated  space,  so  that  these  fibres  completely  surround  the 
corpus  callosum.  OflFsets  from  these  fibres  pass  upwards  and  backwards 
to  reach  the  summits  of  the  secondary  convolutions  derived  from  the  gyrus 
fornicatus  near  the  longitudinal  fissure, 

(iii.)  Longitudinal  septal  fibres  lie  on  the  inner  surface  of  the  septum 
lucidum  and  extend  into  the  gyrus  fornicatus. 

(iv.)  Th.Q  fasciculus  unoinatus  passes  across  the  bottom  of  the  Sylvian 
fissure,  and  connects  the  convolutions  of  the  frontal  and  temporo- 
sphenoidal  lobes. 

(v.)  The  longitudinal  inferior  fasciculus  connects  the  convolutions  of 
the  occipital  with  those  of  the  temporal  lobe. 

(vi.)  The  longitudinal  fibres  of  the  corpus  callosum  (nerves  of  Lancisi) 
connects  the  anterior  and  posterior  ends  of  the  callosal  convolution. 

(c)  The  Ascending  or  Peduncular  Fibres. — The  fibres  which 
connect  the  central  grey  tube  with  the  encephalon  have  already 
been  traced  as  far  as  the  crura.  The  upward  continuation  of 
the  fibres  of  the  anterior  root-zones  of  the  cord  terminate  in 
the  optic  thalamus.  The  posterior  longitudinal  fasciculus  lies 
in  front  of  the  nucleus  of  origin  of  the  third  nerve,  and  when 
the  aqueduct  of  Sylvius  opens  into  the  third  ventricle,  the 
fibres  of  the  fasciculus  bend  outwards  in  the  posterior  commis- 
sure of  the  third  ventricle  to  reach  the  inner  wall  of  the  optic 
thalamus,  where  they  appear  to  terminate.  Meynert  describes 
these  fibres  as  passing  downwards  and  outwards  to  form  part  of 
the  fillet  of  the  crus  cerebri,  but  examination  of  the  crus  in  the 
embryo  does  not  bear  out  this  statement.  The  fibres  of  the 
posterior  longitudinal  fasciculus  are  meduUated  at  an  early 
period  of  embryonic  life,  but  in  a  nine  months  embryo  no 
medullated  fibres  having  the  course  described  by  Meynert  can 
be  seen  in  the  crus  cerebri.  The  fibres  of  the  posterior  com- 
missure, on  the  other  hand,  are  the  first  fibres  of  the  cerebrum 
to  assume  a  medulla  (Flechsig).  The  upward  continuation  of 
the  external  portion  of  the  anterior  root-zone  of  the  cord  lies 
in  the  crus  cerebri  to  the  outside  of  the  third  nerve  and  poste- 
rior longitudinal  fasciculus,  and  the  fibres  of  this  area  are  con- 
tinued upwards  into  the  optic  thalamus,  where  they  form  a  thin 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       455 

stratum  of  fibres  which  separates  the  grey  matter  which  lines 
the  third  ventricle  from  the  rest  of  the  optic  thalamus.  A 
portion  of  the  upward  continuation  of  the  external  part  of  the 
anterior  root-zone  of  the  cord  bends  backwards  in  the  pons  to 
reach  the  corpora  quadrigemina. 


Fig.  217. 


Fqs  ^'^^ 


Fig.  217  (From  Henle's  Anatomie).  Vertical  Section  of  the  Brain  parallel  to  the 
course  of  the  Ascending  Fibres  of  the  Right  Cerebral  Peduncle. — *,  Great  longi- 
tudinal fissure ;  1,  Left ;  and  2,  Eight  hemisphere ;  Lq,  Lamiria  quadJi- 
femina ;  Cn,  Pineal  Gland ;  CcP,  Corpus  callosum ;  Tho,  Thalamus :  Sz, 
triatum  zonale  of  the  thalamus ;  Cs,  Caudate  nucleus ;  Ni,  Lenticular 
nucleus ;  Tbo,  Tuber  olfactorium ;  Cls,  Claustrum ;  Sn,  Locus  niger ;  Ntg, 
Red  nucleus  of  the  tegmentum  ;  Fqs  and  Fqi,  Superior  and  inferior  transverse 
fibres  of  the  pons ;  II',  Optic  tract. 

The  corpora  quadrigemina  are  connected  with  the  optic 
tbalami  by  nervous  tracts,  named  hrachia.  The  cerebellum  is 
connected  with  the  corpora  quadrigemina  by  the  superior 
peduncles.  A  large  number  of  the  fibres  of  the  superior 
peduncles  of  the  cerebellum  decussate  in  the  tegmentum,  so 
that  the  fibres  of  the  one  side  cross  to  become  connected  with 
the  red  nucleus  of  the  opposite  side.     Some  of  these  fibres 


456       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

probably  terminate  in  this  nucleus,  while  others  appear  to 
pursue  an  uninterrupted  course  to  the  brain.  The  course  of  the 
fibres  of  the  superior  peduncles  of  the  cerebellum  is  not  well 
ascertained  beyond  the  red  nucleus.  Some  anatomists  think 
that  these  fibres  terminate  in  the  optic  thalamus,  while  others 
believe  that  they  pass  uninterruptedly  as  a  thin  stratum  of 
fibres  between  the  optic  thalamus  and  the  internal  capsule, 
and  through  the  corona  radiata  to  reach  the  grey  matter  of  the 
central  convoluti&ns. 

Fig.  218. 


Fig.  218  (From  Henle's  Anatomic).  Horizontal  Section  of  the  Hemisphere  of  the 
Brain,  close  to  its  Inferior  Surface. — Lq,  Lamina  quadrigemina ;  A,  Aqueduct 
of  Sylvius ;  Ntg,  Red  nucleus  of  the  tegmentum ;  Rdf,  and  Raf,  Descending 
and  ascending  roots  of  the  fornix ;  Co,  Optic  commissure,  seen  through  the 
floor  of  the  third  ventricle ;  Cs,  Caudate  nucleus  of  the  corpus  striatum ;  Nl, 
The  lenticular  nucleus ;  *,  Division  between  the  two  nuclei  of  the  corpus 
striatum  ;  Spa,  Anterior  perforated  space ;  In,  Island  of  Reil ;  Coa',  Anterior 
commissure ;  Sn,  Substantia  nigra ;  B',  Transverse  section  of  the  crusta  ;  II', 
Optic  tracts ;  Cgl,  External  geniculate  body. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.      457 

The  Internal  Capsule  and  Corona  Radiata. — The  crust  of 
the  cerebral  peduncle  consists  of  bundles  of  longitudinal  fibres 
which  have  ascended  mainly  from  the  anterior  pyramid  of  the 
medulla.    The  crust  of  the  peduncle  is,  however,  much  larger 

Fig.  219. 


Fig.  219  (From  Henle's  Anatomie).  Transverse  Section  of  the  Hemisphere  of  the 
Brain,  at  a  little  higher  elevation  than  Fig.  218.— Cp,  External  capsule ;  Cls, 
Claustrum.     The  remaining  letters  indicate  the  same  as  Fig.  218, 


458       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

than  the  anterior  pyramid,  hence  the  fibres  of  the  latter  must 
have  been  reinforced  in  their  ascent  through  the  pons. 
The  crust  of  the  peduDcle  is  quadrilateral  in  form,  but  in  as- 
cending to  the  hemispheres  it  becomes  flattened  from  above 
downwards,  and  from  within  outwards,  and  the  fibres  spread 
out  like  a  fan,  the  edges  of  which  are  directed  forwards  and 

Fig.  220. 


Fig.  220  (From  Flechsig).  Horizontal  Section  of  the  Brain  of  a  Child  nine  months 
of  age,  the  right  side  being  at  a  someiohat  lower  level  than  the  left  half. — F,  Frontal, 
T8,  Temporo-sphenoidal,  and  O,  Occipital  lobes;  Op,  Operculum;  In,  Island  of 
Keil ;  Cls,  Claustrum ;  /'",  Third  frontal  convolution ;  Th,  Optic  thalamus  ; 
NC,  Caudate  nucleus ;  NG',  Tail  of  caudate  nucleus ;  LN,  Lenticular  nucleus  ; 
I,  II,  III,  First,  second,  and  third  divisions  of  the  lenticular  nucleus ;  EK, 
External  capsule  ;  IK,  Posterior  division,  IE',  Anterior  division,  and  K,  Knee 
of  the  internal  capsule  ;  ah,  ph.  Anterior  and  posterior  horns  respectively  of  the 
lateral  ventricles  ;  gcc.  Knee  of  the  corpus  caUosum ;  sp,  Splenium  ;  mc,  Middle 
commissure  ;  /,  Fornix;  si!.  Septum  lucidum ;  a,  Cornu  Ammonis. 


ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION.       459 

backwards.  The  fan  formed  by  these  fibres  is  bent  into  the 
form  of  an  incomplete  hollow  cone,  having  its  concave  surface 
directed  downwards  and  outwards,  and  its  convex  upwards  and 
inwards.  As  the  fibres  ascend  they  pass  at  first  between  the 
optic  thalamus  and  lenticular  nucleus,  but  higher  up  they  pursue 
their  course  beneath  and  to  the  outside  of  the  thalamus  and 
caudate  nucleus,  and  over  the  lenticular  nucleus.  On  horizontal 
section  of  the  hemisphere,  close  to  the  inferior  surface  of  the  brain, 
the  crusta  is  seen  to  be  of  an  irregularly  quadrilateral  form, 
with  its  long  axis  directed  from  before  backwards  and  from 
within  outwards  {Fig.  218,  B').  At  a  higher  level  the  crust,  or 
what  may  now  be  regarded  as  the  internal  capsule,  is  of  the 
same  general  form  as  in  the  preceding  section,  but  its  long  axis 
is  somewhat  lengthened  in  proportion  to  its  short  axis  (Fig. 
219,  B').  Still  higher  up  the  internal  capsule  has  spread  out 
from  before  backwards,  while  the  anterior  half  forms  an  obtuse 
angle  with  the  posterior.  The  angle  where  the  halves  meet  is 
called  the  hnee  {Fig.  220,  .ST),  while  the  divisions  themselves 
ai'B  called  the  anterior  {Fig.  220,  IK')  and  posterior  segments 
{Fig.  220,  IK)  of  the  internal  capsule. 

Corona  Radiata. — On  emerging  from  the  basal  ganglia  the 
fibres  of  the  internal  capsule  radiate  in  a,ll  directions  to  reach 
the  cortex  of  the  hemisphere,  hence  these  have  been  described 
by  Reil  under  the  name  of  corona  radiata,  and  the  point  at 
which  the  fibres  emerge  from  between  the  ganglia  is  called  the 
foot  of  the  corona  radiata. 

The  following  fibres  may  be  distinguished  in  the  crusta  and 
internal  capsule: — 

(1)  The  sensory  peduncular  tract  and  optic  radiations  of  Gratiolet,  the 
latter  joining  the  internal  capsule  from  the  optic  thalamus;  (2)  the 
pyramidal  tract ;  (3)  fibres  in  the  crust  connecting  the  central  grey  tube 
and  the  corpus  striatum ;  (4)  fibres  issuing  from  the  external  surface  of 
the  optic  thalamus  to  join  the  internal  capsule ;  (5)  fibres  issuing  from 
the  external  surface  of  the  caudate  nucleus  ;  (6)  fibres  ascending  from  the 
superior  and  internal  surface  of  the  lenticular  nucleus  ;  (7)  fibres  already 
described  ascending  from  the  superior  peduncle  of  the  cerebellum ;  (8) 
fibres  from  the  corpus  callosum  (Wernicke). 

(1)  Sensor?/  peduncular  fibres  and  optic  radiations  of  Gratiolet. — The 
posterior  root-zones  and  columns  of  GoU  terminate,  as  we  have  already 
seen,  in  the  triangular  and  clavate  nuclei ;  and  the  connection  between 


460       ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 

these  nuclei  and  the  olivary  body,  and  of  the  latter  with  the  cerebellum,  has 
already  been  sufficiently  described.  It  has  also  been  seen  that  the  sensory 
fibres  cross  in  the  spinal  cord,  but  Meynert  describes  a  sensory  crossing 
which  takes  place  in  the  lower  part  of  the  medulla  oblongata.  According  to 
this  author,  fibres  issue  from  the  nuclei  of  the  cuneate  and  slender  fasciculi 
which  pursue  an  arcuate  course  round  the  central  grey  column,  and  become 
mixed  with  the  fibres  of  the  lateral  column  as  they  bend  forwards  to 
decussate.  As  already  noticed,  Flechsig  thinks  that  these  fibres  curve 
round  the  olivary  body  of  the  same  side,  and  enter  its  substance,  while 
Meynert  thinks  that  they  form  the  outer  fasciculus  of  the  anterior  pyramid 
of  the  medulla  oblongata,  and  ascend  with  the  latter  up  through  the  pons 
to  reach  the  crus  cerebri.  Debove  and  Gombault  describe  an  additional 
crossing  of  sensory  fibres  higher  up  in  the  medulla.  These  fibres  pursue 
an  arcuate  course  from  the  triangular  and  clavate  nuclei,  pass  forwards  to 
the  outside  of  the  olivary  body,  and  then  become  subdivided  into  small 


Pig.  221  (From  Henle's  Anatomie).  Transverse  and  Oblique  Section  of  the  Basal 
Ganglia  slanting  upwards  and  forwards  from  the  anterior  edge  of  the  Pons  (P). — 
B,  Crust  of  the  crus  cerebri;  B',  Radiation  of  the  peduncular  fibres  into  the 
hemisphere ;  Sn,  Locus  niger ;  Ntg,  Red  nucleus  of  the  tegmentum ;  *,  Upper 
portion  of  the  formatio  reticularis;  Tho,  Thalamus  opticus;  Cs,  Caudate 
nucleus;  II',  Optic  tract;  Hp,  Hippocampus. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       461 

fasciculi,  which  penetrate  into  the  posterior  and  external  aspects  of  the 
anterior  pyramid,  and  finally  curve  upwards,  becoming  mixed  with  the 
motor  fibres.  It  is  very  probable  that  these  sensory  fibres  occupy  the 
posterior  and  external  portion  of  the  pyramidal  tract  in  its  ascent  through 
the  pons,  inasmuch  as  bundles  of  fibres  exist  here  which  are  not  so  dis- 
tinctly medullated  in  a  nine  months  human  embryo  as  those  lying  in 


o ^i 


rsA- 


Fia.  222  (Ait«r  Debove  and  Gombault)  -Section  of  the  Anterior  Pyramid  (P)  of 
the  Medulla  Oblongata,  on  a  level  with  the  middle  part  of  the  crossing  of  the 
Sensory  Fibres.— F^,  Sensory  fibres;  FSA,  Posterior  and  external  sensory 
fasciculus  which  does  not  penetrate  into  the  substance  of  the  pyramid ;  E, 
Crossing  of  the  sensory  fibres ;  O,  Nucleus  of  the  pyramid;  Z,  Stratum  zonale. 

front  of  them.  It  has  been  at  least  ascertained  that  the  sensory  fibres 
occupy  the  external  fourth  of  the  crusta,  and  about  the  posterior  third  of 
the  posterior  segment  of  the  internal  capsule  in  their  ascent  towards  the 
cortex  of  the  brain.  These  fibres  do  not  appear  to  be  in  any  way  con- 
nected with  the  optic  thalamus  and  lenticular  nucleus,  but  pass  onwards 
between  them  to  reach  the  cortex  of  the  brain.  In  the  posterior  third  of 
the  posterior  segment  of  the  internal  capsule  the  sensory  fibres  bend 
abruptly  backwards,  and  then  radiate  to  reach  the  convolutions  of  the 
occipital  and  tempore- sphenoidal  lobes.  The  fibres  of  this  tract  are  never 
medullated  in  an  embryo  of  nine  months,  and  can  be  readily  traced 
upwards  in  the  outer  segment  of  the  crusta  and  posterior  segment  of  the 
internal  capsule.  In  addition  to  the  fibres  which  ascend  from  the  spinal 
cord,  medulla  oblongata,  and  pons,  the  sensory  tract  in  the  internal  capsule 
contains  fibres  which  connect  the  first  and  second  cerebral  nerves  with 
the  cortex  of  the  brain. 

The  optic  tracts  take  origin  in  the  basal  ganglia  by  an  internal,  middle, 
and  external  root. 

The  internal  root  consists  of  a  bundle  of  fibres  which  passes  between 
the  external  geniculate  body  and  outer  edge  of  the  crusta,  and  penetrates 
into  the  substance  of  the  internal  geniculate  body,  appearing  to  end  in 
the  anterior  pair  of  corpora  quadrigemina.     Huguemin  has  recently  main- 


462       ANATOMICAL   AND   PHYSIOLOGICAL  INTKODUCTION. 

tained  that  this  root  is  connected  with  the  posterior  pair  of  corpora 
quadrigemina,  either  directly  or  through  the  medium  of  the  external 
geniculate  body. 

The  middle  root  terminates  in  the  external  geniculate  body. 

The  extenml  root  passes  to  the  outside  of  the  external  geniculate  body 
and  penetrates  the  inferior  peduncle  of  the  optic  thalamus  about  ]  2mm.  in 
front  of  the  posterior  border  of  the  pulvinar.  By  extirpating  the  eyeballs 
of  young  hares  Gudden  found  that,  when  the  animals  were  killed  some 
months  subsequently,  the  anterior  pair  of  corpora  quadrigemina,  the  optic 
thalami,  and  the  external  geniculate  bodies  were  atrophied;  while  the 
posterior  pair  of  corpora  quadrigemina  and  the  internal  geniculate  bodies 
were  unaffected.  In  man,  however,  both  the  anterior  and  posterior  pair 
of  corpora  quadrigemina  have  been  found  diminished  in  size  in  cases  of 
long  standing  atrophy  of  the  optic  nerves. 

These  various  roots  of  the  optic  nerves  appear  to  be  connected  with 
the  cortex  of  the  brain  by  means  of  the  fibres  which  have  been  named 
the  optic  radiations  of  Gratiolet.  This  bundle  of  fibres  issues  from  the 
posterior  and  external  border  of  the  optic  thalamus  and  is  closely  applied 
to  the  peduncular  sensory  tract  in  its  passage  through  the  internal  cap- 
sule ;  these  fibres  radiate  backwards  and  upwards  to  be  connected  with 
the  convolutions  of  the  occipital  lobe. 

The  olfactory  lobe,  according  to  Meynert,  divides  in  front  of  the  anterior 
perforated  space  into  an  internal  and  external  olfactory  convolution.  The 
external  convolution  coalesces  with  the  temporal  extremity  of  the  gyrus 
fornicatus  or  the  subiculum  cornu  ammonis.  The  internal  convolution  is 
continuous  with  the  frontal  end  of  the  gyrus  fornicatus,  beneath  which  it 
may  be  recognised  for  some  distance  as  a  distinct  longitudinal  elevation. 

A  considerable  portion  of  the  white  substance  of  the  olfactory  lobe 
traverses  the  corpus  striatum  until  it  meets  the  anterior  commissure 
coming  in  the  opposite  direction.  The  olfactory  fibres  are  supposed  to 
cross  in  the  anterior  commissure,  corresponding  to  the  crossing  of  the  fibres 
of  the  optic  nerves  in  the  chiasma.  After  crossing  these  fibres  appear  to 
ascend  upwards  and  backwards  and  to  join  the  fibres  of  the  optic  radiations 
of  Gratiolet,  and  pass  along  with  them  to  the  convolutions  of  the  cortex 
of  the  occipital  or  temporo-sphenoidal  lobe.  The  posterior  third  of  the 
posterior  segment  of  the  internal  capsule,  therefore,  contains  the  peduncular 
sensory  fibres  and  the  fibres  which  connect  the  optic  nerves,  and  the  olfac- 
tory bulb  with  the  cortex  of  the  brain. 

(2)  The  Pyramidal  Tract. — The  course  of  the  fibres  of  the  pyramidal 
tract  has  already  been  traced  upwards  through  the  spinal  cord,  medulla 
oblongata,  and  pons.  It  remains  to  trace  the  course  of  these  fibres  through 
the  crusta,  internal  capsule,  and  corona  radiata  to  their  destination  in  the 
convolutions  of  the  cortex.  We  have  also  found  that  the  greater  number 
of  the  fibres  of  the  pyramidal  tract  in  the  cord  are  meduUated  in  a  nine 
months  human  embryo,  while  a  large  proportion  of  the  fibres  which  join 
the  tract  in  the  medulla  oblongata  and  pons  are  non-medullated.     The  ex- 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       4G3 

fcernal  portion  of  the  anterior  pyranaids  of  the  medulla  contains  on  the  cue 
hand  meduUated  without  any  admixture  of  non-medullated  fibres,  the 
internal  and  anterior  margin  of  the  pyramid  on  the  other  hand  contains 
non-medullated  without  any  admixture  of  meduUated  fibres,  while  an  area 
lies  between  these  in  which  the  two  kinds  of  fibres  are  mixed.     The  first 

Fig.  223. 


^  i 


arr 


Fig.  223  (Modified  fron    I  ,      /  -se  Section  of  the  Cms  Cerebri  on  a  level 

with  the  anterior  pair  of  Corpora  Quadrigemina,  from  a  nine  months  embryo. — 
cc,  crusta ;  P,  fundamental,  P',  mixed,  and  p,  accessory  portion  of  the  pyra- 
midal tract ;  LN,  locus  niger ;  RN,  red  nucleus  of  the  tegmentum ;  i,  posterior 
longitudinal  fasciculus ;  ar  and  ar',  upward  continuation  of  the  internal  and  ex- 
ternal portions  respectively  of  the  anterior  root-zone  of  the  spinal  cord ;  iii, 
third  nerve  ;  iii',  nucleus  of  the  third  nerve  ;  iv,  fourth  nerve ;  iv',  nucleus  of 
the  fourth  nerve  ;  iv",  crossing  of  the  fibres  of  the  fourth  nerves  to  opposite 
sides  ;  dt,  descending  root  of  the  trigeminus  ;  cc,  aqueduct  of  Sylvius  ;  x,  cross- 
ing of  the  fibres  of  the  superior  peduncles  of  the  cerebellum ;  pf,  fasciculus  of 
meduUated  fibres  proceeding  to  the  anterior  pair  of  corpora  quadrigemina. 


of  these  regions  may  be  called  the  fundamental,  the  second  the  accessory, 
and  the  third  the  mixed  area.  We  have  already  seen  that  in  the  pons  the 
accessory  portion  of  the  pyramidal  tract  lies  internal  to  the  fundamental 
portion,  and  in  the  crusta  they  occupy  the  same  relative  positions.  The 
fundamental  portion  of  the  tract  occupies  the  greater  portion  of  the  middle 


464       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

third  {Fig.  223,  P),  and  the  accessory  portion  the  larger  part  of  the  internal 
third  of  the  crusta  {Fig.  223,  p).  The  mixed  area  of  the  tract  lies  partly 
in  the  middle  third  of  the  crusta  between  the  fundamental  area  and  the 
locus  niger,  and  winds  round  to  the  inside  of  the  fundamental  and 
between  it  and  the  accessory  area  {Fig.  223,  P').  Speaking  broadly,  the 
fundamental  fibres  ascend  in  the  middle  {Fig.  224,  P)  and  the  mixed 
fibres  in  the  anterior  thii-d  of  the  posterior  segment  of  the  internal  capsule 
{Fig.  224,  P'),  while  the  accessory  fibres  ascend  in  the  anterior  segment  of 
the  capsule  {Fig.  224,  p). 

Fig.  224. 


Fig.  224,  Horizontal  Section  of  the  Basal  Ganglia  and  Internal  Capsule  of  a  Nine 
Months  Embryo, — LN,  Lenticular  nucleus  ;  II,  III,  Second  and  third  segments 
of  the  nucleus  respectively  ;  NC,  Caudate  nucleus  ;  Th,  Optic  thalamus  ;  In, 
Island  of  Keil ;  ps,  Peduncular  sensory  tract  and  optic  radiations  of  Gratiolet ; 
P,  Fundamental,  P',  Mixed,  and  p,  Accessory  portion  of  pyramidal  tract ;  C, 
Fibres  from  the  corpus  callosum  (?). 


The  fibres  of  the  pyramidal  tract,  on  emerging  from  between  the  basal 
ganglia,  ascend  in  the  corona  radiata,  and  are  distributed  to  the  convo- 
lutions of  the  cortex  in  the  following  manner  : — The  fundamental  fibres 
pass  to  the  central  convolutions  near  the  margin  of  the  great  longitu- 
dinal fissure.  These  convolutions  are,  briefly,  the  parietal  lobule,  the 
paracentral  lobule,  the  superior  extremities  of  the  ascending  frontal  and 
parietal  convolutions,  and  probably  also  the  posterior  extremity  of  the 
first  frontal  convolution.  These  convolutions  are,  as  we  have  already 
seen,  those  in  which  the  largest  pyramidal  cells  of  the  fourth  layer  of 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       465 

the  cortex  have  been  found.  The  accessory  fibres  are  distributed  to  the 
convolutions  that  constitute  the  operculum.  These  convolutions  are  the 
posterior  extremity  of  the  third  frontal  and  the  inferior  extremities  of 
the  ascending  frontal  and  parietal  convolutions,  and  correspond  to  those 
in  which  the  smaller-sized  pyramidal  cells  with  axis-cylinder  processes 
have  been  observed.  The  mixed  pyramidal  tract  is  distributed  to  the 
convolutions  between  the  two  other  areas.  These  convolutions  are  the 
posterior  extremity  of  the  second  frontal  and  the  middle  of  the  ascending 
and  parietal  convolutions.  What  connection  exists  between  the  pyramidal 
tract  and  the  supra-marginal  and  angular  gyri  has  not  been  ascertained. 

(3)  Fibres  comiecting  the  Central  Grey  Tube  with  the  Corpus  Striatum.. — 
The  first  and  second  divisions  of  the  lenticular  nucleus  are  connected  with 
the  crusta  by  a  band  of  radiating  fibres,  which  in  their  ascent  are  disposed 
in  two  thin  bands,  named  the  strice  medullarea,  and  which  run  parallel  to 


Fig.  225. 


Cs 


^^. 


Tlo 


„--— Oom. 


/ 
/ 


Fig.  225  (From  Henle's  Anatomie).  Transverse  and  Vertical  Section  of  the  Basal 

Ganglia  on  a  level  with  the  Corpora  Caudicantia. 

Cca,  Corpora  albicantia.  Nl,  Lenticular  nucleus . 

Rdf,  Descending  roots  of  the  fornix.  Cst,  Corpus  subthalamicum. 

Com,  Anterior  commissure.  H',  Optic  tracts. 

Tto,  Taenia  of  the  optic  thalamus.  B,  Crust  of  the  cerebral  peduncle. 
Cs,  Caudate  nucleus. 

EE 


466       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

the  outer  surface  of  the  nucleus,  and  divide  it  into  three  zones.  Many 
of  these  fibres  terminate  in  the  substance  of  the  nucleus,  while  others 
pass  through  it  probably  without  interruption.  A  large  number  of  these 
fibres  at  least  pass  transversely  through  the  internal  capsule,  interlacing 
with  its  ascending  fibres,  and  becoming  connected  with  the  optic  thalamus 
and  caudate  nucleus.  Fibres  appear  to  enter  the  crusta  from  the  locus 
niger,  and  it  is  not  improbable  that  the  latter  nucleus  is  to  be  regarded 
as  the  means  of  communication  between  the  anterior  root-zone  of  the 
spinal  cord  and  the  corpus  striatum. 

(4)  Fibres  issuing  from  the  Exteriwd  Surface  of  the  Optic  Tkalamtis  to 
join  the  Internal  Capsule. — The  optic  radiations  of  Gratiolet  already 
described  belong  to  this  system  of  fibres,  inasmuch  as  they  issue  from  the 
external  surface  of  the  posterior  portion  of  the  thalamus.  Other  fibres 
issue  from  the  external  surface  of  the  anterior  two-thirds  of  the  thalamus 
and  join  those  of  the  pyramidal  tract  on  their  way  to  the  cortex. 
The  anterior  radiating  fibres  of  the  thalamus  are  probably  distri- 
buted to  the  convolutions  of  the  frontal  lobe,  and  the  central  radiating 
fibres  to  the  convolutions  of  the  parietal  lobe,  while  as  we  have  already 
seen  the  posterior  radiating  fibres  are  distributed  to  the  convolutions  of 
the  occipital  lobe. 

(5)  Fibres  issuing  from  the  External  Surface  of  the  Caudate  Nucleus. — 
These  fibres  are  described  as  issuing  from  the  external  surface  of  the 
caudate  nucleus,  and  as  passing  into  the  corona  radiata  immediately  above 
and  internal  to  the  radiating  fibres  of  the  optic  thalamus. 

(6)  Fibres  issuing  from  the  Superior  and  Internal  Surface  of  the  Lenticular 
Nucleus  to  join  the  Ascending  Fibres  of  the  Internal  Capsule. — A  large  num- 
ber of  fibres  issue  from  the  superior  and  internal  surface  of  the  lenticular 
nucleus,  and  pass  transversely  through  the  internal  capsule,  interlacing 
with  its  longitudinal  fibres.  Other  fibres  are  described  as  pursuing  an 
ascending  course  parallel  with  the  longitudinal  fibres  of  the  internal  cap- 
sule. The  latter  fibres  are  supposed  to  radiate  in  all  directions  on  gaining 
the  corona  radiata  to  become  connected  with  the  cortex.  It  is  right, 
however,  to  add  that  the  latest  anatomical  researches  throw  considerable 
doubts  upon  the  existence  of  the  radiating  fibres  which  anatomists  have 
described  as  connecting  the  caudate  nuclei  and  the  third  division  of  the 
lenticular  nucleus  with  the  cortex.  Wernicke  states  that  neither  the 
caudate  nucleus  nor  the  third  division  of  the  lenticular  nucleus  are  directly 
connected  with  the  cortex  by  radiating  fibres,  and  he  thinks  that  they 
must  be  regarded  as  independent  ganglia,  like  the  grey  matter  of  the 
cortex  itself.  The  first  and  second  divisions  of  the  lenticular  nucleus 
form  ganglia  of  interruption,  which  connect  the  caudate  nucleus  and  the 
third  division  of  the  lenticular  nucleus  with  the  central  grey  tube. 

(7)  Fibres  Ascending  from,  the  Superior  Peduncle  of  the  Cerebellum. — 
The  red  nucleus  of  the  tegmentum  is  connected,  as  already  described,  with 
the  fibres  ascending  in  the  superior  peduncle  of  the  cerebellum  of  the 
opposite  side.      Fibres  appear  to  ascend  from  the  red  nucleus  to  the 


ANATOMICAL   AND   PHYSIOLOGICAL  INTRODUCTION.       467 

optic  thalamus,  and  Flechsig  supposes  that  some  of  the  fibres  of  the 
superior  peduncle  of  the  cerebellam  of  the  opposite  side  pass  uninter- 
ruptedly through  the  red  nucleus  and  along  the  internal  surface  of  the 
fibres  of  the  pyramidal  tract  to  be  distributed  to  the  central  convolu- 
tions of  the  cerebrum. 

(8)  Fibres  issuing  from  the  Corpus  Callosum  and  Descending  into  the 
Internal  Capsule. — Wernicke  states  that  the  fibres  of  the  corpus  callosum 
which  form  the  anterior  wall  of  the  anterior  horn  of  the  lateral  ventricle 
wind  backwards  along  the  external  border  of  the  caudate  nucleus,  where 
they  become  mixed  with  the  longitudinal  fibres  of  the  internal  capsule 
He  is  unable  to  trace  them  further. 

(9)  Fibres  of  tlie  External  Capsule. — The  fibres  of  the  external  capsule 
either  ascend  from  the  crusta,  pass  along  the  inferior  surface  of  the 
lenticular  nucleus,  and  bend  abruptly  upwards  round  its  inferior  external 
angle  to  reach  the  external  surface,  or  they  take  origin  in  the  cells  of  the 
nucleus,  and  after  issuing  from  its  inferior  surface  pursue  the  course  just 
described.  These  fibres  ascend  along  the  external  surface  of  the  lenticular 
nucleus  forming  the  thin  stratum  of  white  matter  between  it  and  the  claus- 
trum  {Fig.  220,  EK),  and  on  reaching  the  corona  radiata  they  radiate  to 
reach  the  convolutions  of  the  cortex.  The  external  surface  of  the  lenticular 
nucleus  and  the  external  capsule  are  simply  in  contact  with  one  another, 
and  there  appear  to  be  no  connections  formed  between  the  fibres  of  the 
one  and  the  cells  of  the  other.  The  two  surfaces  are,  indeed,  separated  in 
some  places  by  blood-vessels  ascending  from  the  middle  cerebral  artery. 

Besides  those  of  the  internal  capsule  and  corona  radiata,  other 
fibres  connect  the  basal  ganglia  and  the  cortex  of  the  brain. 
These  fibres  consist  of  the  fornix,  tcenia  semicircular  is, 
peduncwlus  septi,  and  a  considerable  proportion  of  the  fibres 
which  constitute  the  collar  or  fillet  of  the  crus. 

The  fornix  arises  in  the  optic  thalamus.  Its  fibres  of  origin  are 
connected  with  the  tcenia  semicircularis  and  the  peduncles  of  the  pineal 
gland.  They  descend  to  the  under  surface  of  each  thalamus,  and  after 
forming  a  loop  in  the  corpora  albicantia  they  ascend  upwards  and  forwards 
in  the  walls  of  the  third  ventricle  as  the  anterior  pillars  of  the  fornix. 
The  fibres  of  each  crus  then  pass  backwards  in  the  body  of  the  fornix, 
and  end  as  the  taenia  hippocampi  in  the  gyrus  of  the  same  name. 

The  tcenia  semicircularis  connects  the  apex  of  the  temporal  lobe  with 
the  whole  length  of  the  internal  margin  of  the  caudate  nucleus.  The  fibres 
which  penetrate  into  the  anterior  region  of  the  head  of  that  nucleus  are 
named  strice  eorneoe. 

The  pedunculus  septi  connects  the  cortical  substance  of  the  septum 
lucidum  with  the  basal  mass  of  the  corpus  striatum. 

The  Collar  or  Fillet  of  the  Crus  Cerebri. — A  bundle  of  fibres  forms  at  the 


468       ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

posterior,  inferior,  and  external  angle  of  the  optic  thalamus,  which  winds 
downwards,  outwards,  and  forwards  round  the  posterior  margin  of  the 
ascending  fibres  of  the  crusta.  These  fibres  are  named  the  inferior  peduncle 
of  the  optic  thalamus,  and  constitute  the  posterior  portion  of  the  collar 
or  fillet  of  the  crus  ;  they  spread  out  on  the  roof  of  the  descending  cornu 
of  the  lateral  ventricle  and  pass  forwards  to  the  convolutions  of  the 
anterior  extremity  of  the  temporo-sphenoidal  lobe.  It  is  probable  that 
some  of  them  also  radiate  backwards  to  reach  the  convolutions  on  the 
inferior  surface  of  the  occipital  lobe.  Other  fibres  appear  to  issue  from 
the  anterior,  inferior,  and  external  angle  of  the  thalamus,  which  wind 
round  the  anterior  border  of  the  crusta,  and  terminate  in  the  lenticular 
nucleus,  or  pass  to  the  convolutions  of  the  temporo-sphenoidal  lobe. 
These  fibres  form  the  anterior  portion  of  the  collar  of  the  crus. 

§  681.  Development  of  the  Brain. — The  cerebral  end  of  the  cerebro- 
spinal tube  is  at  first  uniform  in  appearance  with  the  spinal  part,  but  it 
soon  expands  into  three  vesicular  dilatations — the  primary  cerebral  vesicles. 
These  vesicles  are  named,  from  their  relative  positions,  anterior,  middle, 
and  posterior,  and  the  structures  which  go  to  form  the  several  sub- 
divisions of  the  encephalon  are  produced  in  their  walls. 

l!:\i%  posterior  cerebral  vesicle  first  bends  forwards  to  form  the  medulla 
oblongata,  and  then  backwards  to  form  the  cerebellum,  the  pons  being 
developed  at  the  angle  where  these  two  parts  are  continuous  with  one 
another.  The  cerebellum  consists  at  first  of  a  central  lobe,  and  the 
lateral  lobes  are  only  developed  in  the  mammalia. 

The  middle  cerebral  vesicle  bends  forwards  from  the  posterior  one,  its 
central  hollow  becoming  the  aqueduct  of  Sylvius ;  the  optic  lobes  are 
formed  in  its  roof,  and  the  cricra  cerebri  in  its  floor. 

The  antei'ior  cerebral  vesicle  bends  downwards  from  the  middle  vesicle, 
and  its  central  hollow  becomes  the  third  ventricle.  The  optic  thalami 
form  in  its  lateral  walls,  and  the  pineal  body  in  its  upper  and  posterior 
wall.  The  lamina  cinerea  closes  the  vesicle  in  front.  The  posterior  part 
of  the  anterior  vesicle  gives  off"  from  each  side  a  flask-shaped  prolongation— 
the  primary  optic  vesicle — which  subsequently  forms  the  optic  tract  with 
the  optic  nerve  and  retina. 

The  antero-lateral  part  of  the  cerebral  vesicle  is  prolonged  forwards 
into  two  hollow  processes,  the  hemisphere-vesicles,  from  which  the  cerebral 
hemispheres  are  subsequently  developed.  These  vesicles  are  separated 
from  one  another  by  a  median  longitudinal  fissure,  whilst  the  hollow  in 
the  interior  of  each  forms  the  lateral  ventricle.  On  the  floor  of  this 
vesicle  a  grey  mass  forms  which  may  be  named  the  basal  nucleus,  and 
which  subsequently  develops  into  the  corpus  striatum.  The  remaining 
portions  of  the  walls  of  the  vesicle  form  the  cortex  of  the  brain,  the 
basal  nucleus  and  cortex  being  continuous  in  the  part  which  subsequently 
forms  the  anterior  perforated  space.  When  after  a  time  fibres  shoot 
down  from  the  cortex  to  reach  the  central  grey  tube,  and  shoot  upwards 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       469 

from  the  central  grey  tube,  corpora  quadrigemiaa,  and  optic  thalamus 
to  reach  the  cortex,  they  pursue  the  shortest  course  by  passing 
through  the  basal  mccleus,  so  that  the  latter  becomes  divided  into 
an  inferior  and  external  (the  lenticular),  and  a  superior  and  in- 
ternal portion  (the  caudate  nucleus),  the  two  being  continuous  with  one 
another  and  with  the  cortex  of  the  cerebrum  in  the  anterior  perforated 
space.  The  development  of  the  basal  nucleus  therefore  renders  it  probable 
that  the  corpus  striatum  is  a  modified  portion  of  the  cortex  of  the  brain, 
thus  confirming  the  view  recently  adopted  by  Wernicke.  The  fibres  of 
which  the  fornix  consists  now  appear  on  the  inner  wall  of  the  hemisphere- 
vesicle,  while  the  transverse  fibres  of  the  corpus  callosum  pass  above 
the  plane  of  the  fornix  to  connect  the  cortex  of  one  hemisphere  with 
that  of  the  other.  Between  the  corpus  callosum  and  the  upper  surface  of 
the  fornix,  anteriorly,  two  thin  layers  of  grey  matter  belonging  to  the  inner 
surface  of  each  hemisphere-vesicle  are  enclosed.  These  together  form 
the  laminae  of  the  septum  lucidum,  and  the  cavity  which  separates  them 
becomes  the  fifth  ventricle.  Each  hemisphere-vesicle  gives  ofi"  from  its 
anterior  part  a  hollow  process  which  develops  into  the  olfactory  bulb. 

The  longitudinal  or  collateral  system  of  fibres,  which  connects  the 
occipital  lobe  on  the  one  hand  and  the  temporal  and  frontal  lobes  on 
the  other,  form  a  relatively  thick  white  layer  in  their  passage  through  the 
middle  lobe,  which  cuts  ofi"  the  fifth  from  the  remaining  layers  of  the  cortex 
of  the  Island  of  Reil,  the  detached  portion  being  known  as  the  claustrum. 
It  consists,  as  we  have  seen,  of  fusiform  cells  analogous  to  those  found  in 
the  fifth  layer  in  other  areas  of  the  cortex,  and  which  are  probably  asso- 
ciated in  the  latter  with  the  system  of  arcuate  fibres. 

The  Convolutions. — The  walls  of  the  cerebral  hemispheres  consist  at 
first  of  two  smooth  shell-like  lamellae  which  include  the  cavities  afterwards 
named  the  lateral  ventricles.  The  first  traces  of  the  convolutions  appear 
about  the  fourth  month,  the  primary  sulci  appearing  as  slight  depressions 
on  the  smooth  surface.  The  Sylvian  fissure  begins  as  a  cleft  between  the 
anterior  and  middle  lobes  about  the  fourth  month,  and  is  the  first  fissure 
to  make  its  appearance  after  the  great  longitudinal  fissure.  Soon  after- 
wards the  fissure  of  Rolando  appears  ;  it  is  followed  by  the  parieto-occi- 
pital,  and  at  a  somewhat  later  period  by  the  calloso-marginal  fissure. 
After  the  fifth  month,  the  secondary  fissures  develop  rapidly,  and  all 
the  convolutions  and  fissures  make  their  appearance  towards  the  seventh 
and  eighth  months.  The  hemispheres  do  not  cover  the  optic  thalami 
until  the  third  month,  at  the  fourth  they  reach  the  corpora  quadri- 
gemina,  and  at  the  sixth  month  they  cover  a  great  part  of  the  cerebellum. 

The  convolutions  of  the  human  brain  are  divided  xnio  primary  or  fun- 
damental and  secondary  or  accessory.  The  disposition  of  the  fundamental 
convolutions  is  fixed,  and  corresponds  closely  with  the  arrangement  of  the 
convolutions  in  the  brain  of  the  monkey ;  but  the  disposition  of  the  acces- 
sory convolutions  is  variable,  and  they  must  be  regarded  as  being  super- 
added to  the  former  in  the  course  of  evolution.     The  arrangement  of  the 


470       ANATOMICAL   AND  PHYSIOLOGICAL   INTKODUCTION. 

coQVolutions  of  a  human  embryo  at  the  sixth  month  corresponds  closely 
to  that  of  the  brain  of  the  adult  monkey. 

The  fundamental  convolutions  are  distributed  along  the  margin  of  the 
great  longitudinal  and  other  primary  fissures,  while  the  accessory  convo- 
lutions border  the  secondary  fissures. 

The  grey  matter  of  the  accessory  is  connected  v?ith  that  of  the  funda- 
mental convolutions  by  means  of  arcuate  fibres,  while  the  former  is  not 
directly  connected  with  the  ascending  and  radiating  fibres  of  the  internal 
capsule. 

Another  circumstance  worth  observing  is  that  the  grey  matter  of  the 
summits  of  the  convolutions  is  developed  before  that  at  the  bottom  of  the 
fissures  (Broadbent).    It  must  be  remembered  that  the  growth  of  the  brain 
is  restrained  at  an  early  period  of  embryonic  life  by  the  skull.    The  distri- 
bution of  the  blood-vessels  to  the  brain  is  such  that  the  surface  of  the 
hemisphere  must  be  more  freely  supplied  with  blood  than  the  meduUary 
substance,  and  consequently  the  former  will  grow  at  a  more  rapid  rate 
than  the  latter.    If  then  the  cortex  grow  at  a  more  rapid  rate  than  the 
medullary  substance,  and  be  at  the  same  time  restrained  from  growing 
freely  outwards  by  the  skull,  the  surface  of  the  organ  must  be  thrown  into 
folds.     The  young  nerve  cells  and  fibres  grow  in  the  neighbourhood  of  the 
vessels  and  the  older  ones  are  thrust  away  from  them.    It  follows  that 
when  two  vessels  run  a  more  or  less  parallel  course  on  the  surface  of  the 
brain  the  younger  nerve  cells  and  fibres  lie  near  each  vessel,  while  the 
older  ones  occupy  a  position  midway  between  them.    If  the  surface  of  the 
brain  were  free  to  grow  in  all  directions  like  the  skin,  the  vessels  them- 
selves would  be  thrust  further  apart  during  growth  and  the  surface  would 
remain  more  or  less  smooth ;  but  as  the  surface  of  the  brain  grows  under 
pressure,  the  vessels  cannot  be  thrust  from  each  other  ao  a  sufficiently 
rapid  rate  to  keep  progress  with  the  growth  of  nerve  tissue  between 
them.    The  consequence  is  that  either  the  growth  of  the  nerve  tissue 
between  the  two  vessels  must  be  arrested,  or  a  fold  must  be  formed  so 
that  the  grey  matter  between  them  may  pursue  a  curved  instead  of  a 
straight  course.    If  this  be  an  approximately  accurate  account  of  the  way 
in  which  the  cerebral  convolutions  are  formed,  it  will  be  readily  seen  that 
the  earlier-formed  nerve  cells  and  fibres  occupy  the  summits  of  the  convo- 
lutions, while  the  later-formed  cells  and  fibres  occupy  the  bottom  of 
the  fissures.     It  may  be  noticed,  in  confirmation  of  this  view,  that  the 
summits  of  the  convolutions  are  alone  directly  connected  with  the  pedun- 
cular and  radiating  fibres,  while  the  grey  matter  of  the  fissures  is  only 
connected  with  them  indirectly  through  that  of  the  summits  by  means  of 
arcuate  fibres.    The  depth  of  the  fissures  may,  therefore,  be  taken  along 
with  the  complexity  of  the  arrangement  of  the  convolutions  and  other 
circumstances  as  a  measure  of  the  degree  of  development  of  the  brain. 
The  distribution  of  the  blood-vessels  of  the  cortex  would  also  lead  us  to 
expect  that  the  superficial  layer  next  the  pia  mater  is  the  embryonic 
layer  of  the  grey  matter,  while  the  earlier-formed  portions  occupy  the 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       471 

position  furthest  removed  from  the  vessels,  and  consequently  consist  of 
the  internal  layers  with  caudate  cells. 

§  682.  Differences  hetween  the  brain  of  the  adult  man  and  that  of  the  higher 
mammalia  and  human  infant.— The  usual  information  given  in  anatomical 
works  with  regard  to  the  size  and  weight  of  the  human  brain  as  compared 
with  that  of  animals  will  be  passed  over  here  in  order  to  insist  upon  less 
conspicuous,  but  probably  not  less  important,  differences. 

There  has  been  a  widely-spread  belief  that  the  large  development  of  the 
frontal  lobes  is  peculiarly  characteristic  of  the  brain  of  man,  but  some 
years  ago  Dr.  Carpenter  drew  attention  to  the  fact  that  in  the  lower  forms 
of  animals  the  cerebellum  is  entirely  uncovered  by  the  cerebrum,  that  it 
is  only  partially  covered  by  the  posterior  lobes  in  the  more  intelligent 
animals,  such  as  dogs  and  monkeys,  and  that  it  is  only  in  man  that  the 
posterior  lobes  of  the  cerebrum  completely  overlap  the  cerebellum.  Dr. 
Carpenter  argued  from  this  that  the  increase  of  the  posterior  lobes  is  more 
characteristic  of  advance  in  development  than  that  of  the  anterior  lobes. 
But  he  ignores  the  fundamental  facts  of  development,  while  regarding 
superficial  appearance.  If  we  take  the  fissure  of  Rolando,  or  the  central 
sulcus  in  animals,  as  the  line  which  separates  the  frontal  from  the 
parietal  lobe,  it  will  be  noticed  how  small  a  portion  of  the  brain  lies 
anterior  to  the  sulcus  in  such  animals  as  the  rabbit  {Fig.  226,  r),  which 

Fig,  226. 


Fig.  226  (Modified  from  Ferrier).  Brain  of  Rabbit.— 0,  Olfactory  bulb ;  r,  Central 
sulcus  ;  X ,  Parallel  sulcus ;  M,  Motor  area ;  A,  Anterior  or  psychical  area ; 
P,  Posterior  or  sensory  area. 

is  one  of  the  lowest  animals  in  which  the  sulcus  is  developed.  Even  in 
the  dog  and  monkey  only  a  relatively  small  part  of  the  brain  lies  anterior 
to  this  sulcus  compared  to  the  large  mass  which  lies  behind  it.  And 
a  study  of  the  development  of  the  human  brain  shows  that  the  occipital 
and  parietal  lobes  increase  rapidly  at  an  early  period  in  the  develop- 
ment of  the  embryo,  while  the  frontal  lobes  increase  chiefly  during 
the  later  months  of  foetal  life.  The  portion  which  lies  in  front  of 
the  sulcus  of  Rolando  in  a  six  months  human  foetus  (Fig.  227,  r)  is 
small,  while  the  sulcus  itself  is  directed  vertically  upwards  in  a  line 
with  the  anterior  ascending  limb  of  the  fissure  of  Sylvius ;  the  superior 
extremity  being  somewhat  anterior  to  the  inferior  extremity.  In  the  brain 
of  the  human  adult  the  superior  extremity  of  the  sulcus  of  Rolando  is 
pushed  backwards,  owing  to  the  great  increase  of  the  frontal  lobes,  so 


472       ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION. 

that  a  vertical  line  drawn  from  it  would  pass  through  the  posterior  ex- 
tremity of  the  horizontal  limb  of  the  Sylvian  fissure.  During  the  develop- 
ment of  the  human  brain  the  superior  extremity  of  the  sulcus  of 
Rolando  therefore  sufiers  a  backward  displacement  in  order  to  make  room 
for  the  increasing  size  of  the  anterior  area  of  the  cortex  ;  and,  similarly, 
in  the  evolution  of  the  human  brain  from  the  simian  type  the  occipital 
lobes  have  undergone  a  posterior  displacement  in  order  to  make  room  for 
the  relatively  large  increase  of  size  of  the  frontal  lobes,  hence  the  covering 
of  the  cerebellum  is  not  caused  directly  by  an  increased  size  of  the  occi- 
pital, but  indirectly  by  an  increased  size  of  the  frontal  lobes. 

Fig.  227. 


Fig.  227  (From  Quain,  after  Wagner).  External  Surface  of  the  Fcetal  Brain  at  Six 
Months.~F,  Frontal  lobe.  P,  Parietal  lobe.  O,  Ocoipital  lobe.  T,  Temporal 
lobe,  a,  a,  a,  Slight  appearance  of  the  several  frontal  convolutions.  S,  Sylvian 
fissure ;  S',  its  anterior  division.  C,  Convolutions  of  the  island,  r,  Fissure  of 
Rolando,    p,  External  part  of  the  vertical  fissure. 


Another  remarkable  feature  in  which  the  human  brain  differs  from 
that  of  animals  is  the  manner  in  which  the  Island  of  Reil  is  completely 
surrounded,  and  hidden  out  of  view  by  deep  convolutions.  This  is  brought 
about  by  the  large  development  of  the  posterior  extremity  of  the  inferior 
frontal,  the  inferior  extremities  of  the  ascending  frontal  and  parietal 
convolutions,  and  of  the  supra-marginal,  angular,  and  inferior  temporo- 
sphenoidal  gyri.  It  appears  to  me  that  the  cortex  of  the  central  lobe, 
starting  from  the  grey  matter  of  the  anterior  perforated  space,  is  the 
embryonic  portion  of  the  cortex  of  the  brain,  just  as  the  central  grey 
column  is  the  embryonic  portion  of  the  grey  matter  of  the  spinal  cord. 
The  anterior  perforated  space  is  a  point  where  the  grey  matter  of  the  two 
nuclei  of  the  corpus  striatum  and  of  the  cortex  of  all  the  lobes  of  the 
brain  meet,  and  it  may  therefore  be  regarded  as  the  starting  point  of  the 
whole  of  the  grey  matter  derived  from  the  primary  cerebral  vesicles. 
On  the  supposition  that  the  portion  of  the  central  lobe  which  lies  in 
the  line  of  distribution  of  the  Sylvian  artery  is  the  embryonic  portion  of  the 
convolutions  of  the  central  or  motor  area  of  the  brain,  it  may  be  expected 
that  the  earlier-formed  portions  of  ISiese  convolutions  will  be  thrust  up- 
wards towards  the  great  longitudinal  fissure,  while  the  later-formed  por- 
tions approach  nearer  and  nearer  to  the  root  of  the  artery.     According  to 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.       473 

this  supposition  therefore  the  fundamental  portions  of  the  convolutions 
supplied  by  the  Sylvian  artery  will  be  found  near  the  great  longitudinal 
fissure,  and  the  accessory  portion  low  down,  near  the  root  of  the  artery, 
the  latter  corresponding  to  the  convolutions  named  the  operculum, 
which  is  so  highly  developed  in  man. 

The  great  development  of  the  supra-marginal  and  angular  gyri  is  also  a 
characteristic  feature  of  the  brain  of  man. 

FUNCTIONS    OF   THE    ENCEPHALON. 
The  functions  of  the  medulla  oblongata  have  already  been 
described  in  detail,  and  those  of  the  pons,  corpora   quadri- 
gemina,  and  crura  cerebri  in  a  general  way. 

§  683.  Functions  of  the  Cerebellum. — The  cerebellum  is, 
according  to  the  view  adopted  in  these  pages,  an  organ  of  com- 
pound co-ordination  in  space,  and  regulates  the  continuous 
muscular  actions  which  are  necessary  for  the  maintenance  of 
certain  attitudes  in  space.  Flourens  observed  that  when  a 
small  portion  of  the  cerebellum  was  removed  from  a  pigeon,  the 
animal's  gait  became  unsteady,  and  that  when  larger  portions 
were  taken  away,  the  movements  became  much  more  disorderly. 
Section  of  the  middle  peduncle  gives  rise  to  a  forced  movement, 
the  animal  rolling  round  its  longitudinal  axis,  and  the  rotation 
being  generally  towards  the  side  operated  upon.  Injury  of  the 
lateral  lobe  of  the  cerebellum,  and  probably  of  the  fibres  of  the 
peduncle  as  they  pass  transversely  through  the  pons,  produces 
the  same  forced  movements  as  section  of  the  middle  peduncle. 
Nothnagel  concludes  from  experiments  on  rabbits  that  lesions 
which  injure  the  fibres  uniting  the  two  sides  of  the  organ 
occasion  the  greatest  amount  of  motor  disturbance. 

Ferrier  found  that  electric  stimulation  of  the  cortex  of  the 
cerebellum  in  animals  caused  movements  of  both  eyes,  with 
associated  movements  of  the  head,  limbs,  and  pupils. 

§  684.  Functions  of  the  Basal  Ganglia.— The  most  generally 
received  hypothesis,  especially  in  England,  with  respect  to 
the  functions  of  these  ganglia  is  that  the  optic  thalami  are 
concerned  in  the  upward  transmission  and  elaboration  of  cen- 
tripetal impulses ;  and  the  corpora  striata  in  the  downward 
transmission    and    elaboration    of  centrifugal  impulses.     The 


474       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

impulses  elaborated  by  the  thalami  may  either  be  transmitted 
anteriorly  and  laterally  to  the  corpora  striata,  or  upwards  to  the 
grey  matter  of  the  cortex,  while  the  incitement  to  action  may 
come  to  the  corpora  striata  either  from  the  thalami  directly  or 
from  the  cortex.  When  the  impulses  are  transmitted  directly 
from  the  thalami  to  the  corpora  striata,  and  from  the  latter 
downwards  to  the  cord,  then  the  basal  ganglia  may  be  regarded 
as  the  superordinates  of  the  central  grey  tube ;  but  when  the 
impulses  are  transmitted  from  the  thalami  to  the  cortex,  and 
from  the  latter  to  the  corpora  striata,  the  basal  ganglia,  although 
still  the  superordinates  of  the  central  grey  tube,  are  the  subor- 
dinates of  the  grey  matter  of  the  cortex. 

Very  serious  objections  have  been  urged  against  the  view  that  the 
thalamus  is  the  sensory  ganghon  of  the  opposite  half  of  the  body,  but 
these  have  been  fairly  answered  by  Dr.  Broadbent,  to  whose  writings 
we  are  indebted  for  two  most  fruitful  discoveries  in  the  application  of 
physiological  principles  to  the  elucidation  of  the  phenomena  of  diseases 
of  the  nervous  system. 

The  first  objection  is,  that  lesion  of  the  thalamus  does  not  impair  sen- 
sation in  the  same  degree  that  motor  paralysis  is  caused  by  injury  of  the 
corpus  striatum  ;  but  the  reply  is,  that  centripetal  currents  are  more 
difi'usely  conducted  than  centrifugal  currents,  and  that  this  feature  is  as 
characteristic  of  the  grey  matter  of  the  posterior  horns  of  the  cord  as  it 
is  of  the  thalamus.  Another  objection  is,  that  if  the  thalamus  be  the 
common  sensory  ganglion,  lesion  of  it  ought  to  cause  not  only  hemi- 
ansesthesia,  but  also  unilateral  blindness  and  deafness.  To  this  objection 
Dr.  Broadbent  replies  by  extending  his  principle  of  the  bilateral  association 
of  the  nerve-nuclei  of  muscles  bilaterally  associated  in  action  to  the  func- 
tions of  the  nerves  of  special  sense.  Bilateral  association  of  sensation  ought 
to  involve  fusion  of  sensory  nuclei,  and  the  combination  of  sounds  reach- 
ing the  ears,  and  of  light  reaching  the  retinse,  being  completely  fused  into 
one  sensation,  the  two  auditory  and  the  two  optic  nuclei  ought  to  be  fused 
practically  into  one,  so  that  unilateral  deafness  or  blindness  from  injury 
to  one  thalamus  becomes  thus  impossible.  Another  objection  to  this 
view  is,  that  while  lesion  of  the  thalamus  is  frequently  unaccompanied  by 
complete  hemiansesthesia,  it  is  sometimes  accompanied  by  motor  paralysis 
of  the  opposite  side  of  the  body ;  from  this  it  has  been  argued  that  the 
thalamus  is  a  superior  centre  for  reflex  action  (Crichton  Browne).  It 
must,  however,  be  remembered  that  the  pyramidal  fibres  of  the  internal 
capsule  lie  almost  immediately  external  and  inferior  to  the  thalamus,  so 
that  disease  of  the  latter  may  readily  implicate  the  former,  and  then 
paralysis  of  the  opposite  side  result. 

The  hypothesis,  therefore,  that  the  thalamus  is  a  centre  for  the  com- 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION.       475 

pound  co-ordination  of  centripetal  impulses  is  not  open  to  any  insuperable 
objections,  and  accords  better  with  facts  than  any  other  theory  of  its 
function.  The  compound  co-ordinated  centripetal  impressions  may  be 
transmitted  directly  to  the  corpus  striatum,  and  reflected  downwards  to 
the  anterior  horns  and  anterior  root-zones  of  the  cord,  thus  causing  a 
compound  reflex  action,  or  upwards  to  the  cortex  of  the  brain,  whex'e  the 
impressions  become  correlated  with  feeling.  There  are  no  sufficient  grounds 
for  believing  that  the  activity  of  the  thalamus  implies  consciousness,  even 
of  the  most  rudimentary  kind.  A  compound  difiers  from  a  simple  reflex 
action  not  only  as  being  more  complex,  but  also  as  consisting  of  a  suc- 
cession of  different  actions.  The  act  of  sucking  in  an  infant  is  a  complex 
act,  but  it  consists  of  a  series  of  similar  complex  actions  in  response  to  a 
series  of  similar  impressions,  and  this  action  may  be  taken  as  a  good 
example  of  reflex  actions  in  general.  But  when  a  chicken  has  just  burst 
the  shell,  and  almost  immediately  begins  to  pick  grains  of  food  ofi"  the 
ground,  the  necessary  actions  are  not  only  complex,  but  consist  of  a 
succession  of  different  complex  actions  in  response  to  different  complex  im- 
pressions. There  is  no  reason  to  believe  that  the  latter  action  is  a  con- 
scious one,  any  more  than  that  of  sucking  in  an  infant ;  but  while  the 
latter  is  a  simple  reflex  action,  and  co-ordinated  in  the  central  grey  tube, 
the  former  is  a  compound  reflex  action,  and  co-ordinated  in  the  basal 
ganglia  acting  in  association  with  the  central  grey  tube  and  probably  also 
with  the  cerebellum.  When  impressions  are  made  upon  a  large  number 
of  the  end  organs  of  the  afferent  nerves,  these,  after  being  first  co-ordinated 
in  the  posterior  part  of  the  grey  matter  of  the  central  grey  tube,  undergo, 
on  ascending,  a  second  co-ordination  in  the  thalami,  whereby  they  are 
integrated  in  various  ways,  and  reduced  to  something  like  serial  order. 
When  the  centripetal  impulses  so  arranged  are  transmitted  to  the  corpora 
striata,  and  reflected  downwards,  they  give  rise  to  a  succession  of  muscular 
contractions  ;  when  again  they  are  transmitted  to  the  cortex — which  is,  as 
we  have  already  remarked,  the  organ  of  doubly  compound  co-ordination  in 
time — their  serial  order  adapts  them  for  evoking  the  rhythmical  sequences 
of  centrifugal  impulses  which  regulate  complex  psychical  actions. 

The  corpus  striatum,  on  the  other  hand,  is  a  centre  for  the 
compound  co-ordination  of  centrifugal  impulses  for  the  opposite 
half  of  the  body.  "When  it  acts  in  obedience  to  impulses  received 
from  the  optic  thalamus,  it  is  an  organ  of  compound  reflex  action. 
All  the  actions  which  are  regarded  as  inherited  instincts,  or 
which  through  long-continued  repetition  have  assumed  the  cha- 
racter of  acquired  instincts,  are  of  the  nature  of  compound  reflex 
actions;  they  are  or  have  become  independent  of  conscious- 
ness, and  are  co-ordinated  in  the  basal  ganglia.  But  the  corpus 
striatum  is  supposed  to  act  in  obedience  to  impulses  received 


476       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

through  the  cortex  of  the  brain.  We  have  already  seen  that 
there  is  an  uninterrupted  connection  between  the  cortex  and 
grey  matter  of  the  cord  by  means  of  the  pyramidal  fibres,  and 
we  must  now  endeavour  to  differentiate  the  functions  of  the 
cortex  when  it  acts  through  the  latter  fibres  and  through  the 
corpus  striatum  respectively.  A  simple  illustration  will  make 
this  clear.  When  a  child  is  learning  to  write,  the  muscles  of 
the  thumb,  index,  and  middle  fingers  are  moved  in  separate 
groups,  so  that  the  fingers  are  ultimately  brought  to  a  proper 
attitude  for  holding  the  pen.  Subsequently  the  separate 
groups  of  muscles  are  brought  successively  into  action, 
whereby  the  point  of  the  pen  is  moved  upwards,  downwards, 
and  laterally,  so  as  to  produce  the  elementary  strokes  of 
writing.  These  actions,  described  in  subjective  terms,  are 
not  simply  conscious,  but  involve  that  active  consciousness 
which  constitutes  attention,  and  they  are  also  deliberate,  the 
outward  sign  of  deliberation  being  slowness  of  execution.  The 
centrifugal  impulses  which  initiated  these  movements  may  be 
presumed  to  have  passed  through  the  pyramidal  fibres.  After 
long-continued  habit,  however,  the  actions  involved  in  writing 
are  to  a  large  extent,  if  not  wholly,  unconscious,  and  demand 
no  deliberation,  and  this  absence  of  deliberation  is  accompanied 
by  extreme  rapidity  of  execution.  The  centrifugal  impulses 
regulating  these  actions  are  co-ordinated  in  the  corpus  striatum, 
under  the  guidance  of  a  relatively  small  number  of  impulses 
from  the  cortex.  This  illustration  also  shows  that  the  progress 
of  education  is  from  actions  which  are  at  first  regulated  through 
the  pyramidal  fibres,  to  actions  which  are  regulated  through  the 
corpus  striatum. 

The  characteristics  of  the  actions  regulated  through  the  pyramidal 
fibres  are,  that  they  are  complex,  slowly  executed,  and  grouped  iu  an  un- 
usual manner ;  while  the  characteristics  of  the  actions  which  are  regulated 
through  the  corpus  striatum  are,  that  they  are  quickly  executed,  and 
arranged  in  frequently  repeated  combinations.  Now,  the  slowly  executed 
movements  grouped  in  unusual  ways  precede  in  the  order  of  development 
the  quickly  executed  and  habitual  movements,  and  the  structural  corre- 
lative of  this  fact  is,  that  in  the  course  of  development  the  pyramidal 
fibres  assume  a  medullary  sheath  some  time  before  the  fibres  in  the  crusta 
which  connect  the  cord  with  the  corpus  striatum.  All  the  complex  move- 
ments which  animals  manifest  in  response  to  emotional  disturbances  are 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.        477 

organised  in  the  corpora  striata.  The  attitude  expressive  of  fear  and  anger 
assumed  by  a  cat  when  threatened  by  a  dog  may  be  taken  as  a  familiar 
example  of  such  actions.  Mr.  Darwin's  description  of  this  attitude  is  that 
the  cat  "  arches  its  back  in  a  surprising  manner,  erects  its  hair,  opens  its 
mouth,  and  spits,"  The  regulation  of  the  muscular  movements  concerned 
in  producing  this  attitude  is  organised  mainly  in  the  corpora  striata,  but 
the  incitement  to  the  action  of  these  centres  in  such  a  case  comes  from 
the  cortex. 

My  friend  Dr.  Noble,  of  Manchester,  whose  work  "  On  the  Human 
Mind  in  its  relations  with  the  Brain  and  Nervous  System  "  was  so  much 
in  advance  of  the  time  in  which  it  was  written,  was  the  first  to  suggest 
that  the  movements  which  are  in  relation  with  the  desires  and  emotions 
are  regulated  through  the  basal  ganglia  acting  in  subordination  to  the 
cortex  of  the  brain  ;  but  this  view,  like  many  of  his  other  opinions,  did 
not  then  attract  the  attention  it  deserved. 

To  illustrate  the  functions  of  the  basal  ganglia,  let  us  suppose  that  an 
impression  is  made  on  the  retina  by  a  minute  object,  such  as  a  fly, 
approaching  the  eye.  The  eyelids  immediately  close.  This  action  is 
purely  reflex,  and  is  determined  by  the  corpora  quadrigemina  and  cord, 
uninfluenced  by  the  basal  ganglia  Part  of  the  disturbance,  however,  is 
conveyed  to  the  optic  thalami,  and  by  them  co-ordinated  in  such  a  way 
that  on  reaching  the  cortex  of  the  brain  they  give  rise  to  a  sensation,  or 
even  to  an  indistinct  perception,  but  the  closure  of  the  lids  is  quite 
independent  of,  and  prior  in  time  to,  the  sensation  or  perception.  Let 
us  now  suppose  that  the  impression  on  both  retinee  is  made  by  a  larger 
body,  such  as  a  cricket-ball,  at  a  considerable  distance  from  the  eyes,  but 
moving  towards  them.  The  disturbances  produced  are  conducted  inwards 
by  the  optic  nerves  and  the  afferent  nerves  of  the  ocular  muscles,  and  after 
being  elaborated  by  the  sensory  part  of  the  grey  matter  of  the  pons  and 
corpora  quadrigemina,  some  of  them  pass  upwards  to  reach  the  cortex 
through  the  sensory  fibres  of  the  internal  capsule,  while  others  are  con- 
ducted to  the  thalami,  and  after  having  undergone  a  second  elaboration 
and  reduction  to  something  like  serial  order,  they  also  are  transmitted 
to  the  cortex.  The  mental  correlative  of  the  cortical  disturbance  is  a 
perception  of  the  object  and  of  its  position  in  space,  and  of  the  rate 
and  direction  of  its  motion.  Centrifugal  impulses  may  now  be  sent 
from  the  cortex  to  the  inferior  centres,  which  will  eventuate  in  a  series 
of  movements,  either  to  catch  the  ball  or  to  avoid  collision  with  it. 
One  man,  in  whom  no  special  aptitude  has  been  organised  with  respect 
to  the  motion  of  the  ball,  may  simply  move  his  head  to  one  side  to 
avoid  collision.  The  slower  the  execution  is  the  more  sure  we  are  that 
it  has  not  been  frequently  repeated  in  the  previous  experience  of  the 
individual,  and  that  it  has  been  determined  by  conscious  and  volitional 
mpulses.  In  such  a  case  the  volitional  or  centrifugal  impulses  are  con- 
ducted outwards  through  the  pyramidal  fibres,  and  the  corpora  striata 
have  had  nothing  to  do  with  it.     Another  man,  or  rather  a  woman,  on 


478       ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION, 

seeing  the  ball  may  exhibit  the  outward  manifestations  of  alarm  by 
facial  expression  or  screaming,  and  execute  a  series  of  locomotive  actions 
far  greater  than  necessary  to  avoid  collision  with  the  ball,  and  the  greater 
these  outward  manifestations  are,  the  more  certain  we  may  be  that  the 
sensory  impressions  on  reaching  the  cortex  have  caused  a  profound 
emotional  disturbance,  and  that  the  centrifugal  impulses  reach  the 
periphery  through  the  corpora  striata.  But  a  third  man,  instead  of 
endeavouring  to  avoid  collision,  may  put  up  both  hands  so  as  to  catch 
the  ball.  Now,  the  centrifugal  impulses  may  pass  in  this  case  either 
through  the  pyramidal  fibres  or  corpora  striata,  according  to  circum- 
stances. If  the  action  have  been  frequently  repeated  so  that  it  be 
done  with  precision,  and  without  a  feeling  of  conscious  effort,  its  regula- 
tion is  organised  in  the  corpora  striata  ;  and  if  it  be  done  awkwardly,  and 
with  the  inward  feeling  and  outward  manifestation  of  a  conscious  effort, 
then  the  centrifugal  impulses  have  passed  through  the  pyramidal  fibres. 

It  must,  however,  be  admitted  that  the  foregoing  account  of  the  func- 
tions of  the  basal  ganglia  is  by  no  means  fully  established.  We  have 
already  stated  that  the  internal  surface  of  the  optic  thalamus  is  lined  by  a 
layer  of  grey  substance  which  represents  the  upper  end  of  the  central  grey 
tube,  and  that  the  upward  continuations  of  the  anterior  root-zone  of  the 
cord  terminated  in  this  ganglion,  and  consequently  it  must  be  presumed 
that  a  portion  at  least  of  the  thalamus  is  endowed  with  motor  functions. 
The  opinion  that  the  optic  thalami  is  a  high  reflex  centre  has  been  ably 
sustained  by  Dr.  Crichton  Browne  on  pathological  grounds.  The 
anatomical  difficulties  which  stand  in  the  way  of  regarding  the  corpus 
striatum  as  an  intermediate  ganglion  between  the  cortex  of  the  brain  and 
the  central  grey  tube  are  also  very  great.  The  latest  researches  of  Wer- 
nicke appear  to  show,  as  we  have  seen,  that  neither  the  lenticular  nor  the 
caudate  nucleus  possess  radiating  fibres ;  and  if  this  be  the  case,  the  corpus 
striatum  must  be  regarded  as  a  nerve  centre  co-ordinate  with  and  not 
subordinate  to  the  cortex.  Ferrier  observed  that  when  the  corpora  striata 
were  stimulated  by  a  strong  interrupted  current,  the  muscles  of  the  oppo- 
site side  of  the  body  became  strongly  contracted ;  but  it  is  impossible  to 
prevent  even  weak  currents  through  the  corpus  striatum  from  affecting  the 
fibres  of  the  internal  capsule,  and  the  spasm  of  the  opposite  side  would  be 
probably  caused  by  irritation  of  the  fibres  of  the  pyramidal  tract.  AVe  shall 
hereafter  see  that  when  hemiplegia  occurs  from  hsemorrhage  into  the  corpus 
striatum,  the  patient  recovers  if  the  fibres  of  the  pyramidal  tract  remain 
uninjured.  Nothnagel  found  that  destruction  or  injury  to  a  particular 
part  of  the  caudate  nucleus  gave  rise  in  the  rabbit  to  remarkable  forced 
movements. 

§  685.  Functions  of  the  Cortex  of  the  Cerebrum. — The  cortex 
of  the  cerebrum  is  probably  the  exclusive  seat  of  psychical  action, 
and  there  seem  to  be  no  grounds  for  .believing  that  the  activity  of 
any  other  portion  of  the  encephalon  is  necessarily  connected  with 


ANATOMICAL   AND  PHYSIOLOGICAL  INTEODUCTION.       479 

even  the  crudest  consciousness.  But  before  we  can  refer  certain 
states  of  consciousness  to  definite  processes  in  the  cortex  of  the 
cerebrum,  it  is  necessary  to  have  a  classification  of  mental 
phenomena,  for  no  decided  progress  can  be  made  in  interpreting 
the  results  of  experiments  on  the  cortex  of  the  brain  until  the 
true  nature  of  a  psychical  action  is  defined  and  some  rational 
classification  of  psychical  states  is  adopted  by  physiologists. 

Nature  of  Psychical  Actions. — We  have  already  seen  that 
simple  reflex  adapted  actions  consist  of  a  series  of  simiiarcomplex 
movements  evoked  by  a  series  of  similar  impressions,  and  that 
compound  reflex  adapted  actions  consist  of  a  series  of  different 
complex  movements  evoked  by  a  series  of  different  impressions ; 
and  we  must  now  endeavour  to  show  wherein  true  psychical 
action  differs  from  simple  and  compound  reflex  actions.  Reflex 
actions,  both  simple  and  compound,  consist  of  three  factors  : 
(1)  conduction  to  a  nerve  centre  of  an  impression  made  on  the 
surface ;  (2)  reduction  to  order  of  these  impressions  in  the 
centre ;  and  (3)  conduction  of  these  outwards,  with  the  muscular 
contractions  resulting  from  them.  But,  as  has  been  frequently 
stated  by  Mr.  Herbert  Spencer,  four  factors  may  be  distinguished 
in  every  psychical  action.  To  quote  Mr.  Spencer's  own  language, 
"  there  is  {a),  that  property  of  the  external  objects  which 
primarily  affects  the  organism — the  taste,  smell,  or  opacity; 
and,  connected  with  such  property,  there  is  in  the  external 
object  that  character  (6)  which  renders  seizure  of  it,  or  escape 
from  it,  beneficial.  Within  the  organism  there  is  (c),  the  im- 
pression or  sensation  which  the  property  {a)  produces,  serving 
as  stimulus ;  and  there  is,  connected  with  it,  the  motor  change 
{d),  by  which  seizure  or  escape  is  effected.  Now  psychology 
is  chiefly  concerned  with  the  connection  between  the  relation 
ah,  and  the  relation  cd,  under  all  those  forms  which  they 
assume  in  the  course  of  evolution.  Each  of  the  factors,  and 
each  of  the  relations,  grows  more  involved  as  organisation 
advances.  Instead  of  being  single,  the  identifying  attribute  a, 
often  becomes,  in  the  environment  of  a  superior  animal,  a 
cluster  of  attributes,  such  as  the  size,  form,  colours,  motions, 
displayed  by  a  distant  creature  that  is  dangerous.  The 
factor  h,  with  which  this  distant  combination  of  attributes  is 
associated,  becomes  the  congeries  of  characters,  powers,  habits. 


480       ANATOMICAL  AND   PHYSIOLOGICAL   INTEODUCTION. 

which  constitutes  it  an  enemy.  Of  the  subjective  factors,  c 
becomes  a  complicated  set  of  visual  sensations  co-ordinated 
with  one  another  and  with  the  ideas  and  feelings  established 
by  experience  of  such  enemies,  and  constituting  the  motive  to 
escape ;  while  d  becomes  the  intricate,  and  often  prolonged, 
series  of  runs,  leaps,  doubles,  dives,  &c.,  made  in  eluding  the 
enemy," 

Classification  of  P/sychical  States. — Various  classifications  of 
mental  states  might  be  adopted,  but  the  best  is  clearly  that 
which  involves  the  fewest  assumptions  and  theoretical  implica- 
tions, and  which  will  enable  us  at  the  same  time  to  connect 
mental  phenomena  with  the  facts  of  development  and  experi- 
mental physiology. 

"  It  would  be  the  greatest  benefit  to  mental  science,"  says  Max 
Miiller,  "  if  all  such  words  as  perception,  intuition,  remember- 
ing, ideas,  conception,  thought,  cognition,  senses,  mind,  intellect, 
reason,  soul,  spirit,  etc.,  could  for  a  time  be  struck  out  of  our 
philosophical  dictionaries,  and  not  be  admitted  again  till  they 
had  undergone  a  thorough  purification."  This  passage  expresses 
a  state  of  mind  which  has  been  felt  by  almost  everyone  who 
has  seriously  engaged  in  psychological  study ;  and  Mr.  Herbert 
Spencer,  whose  great  works  have  formed  an  era  in  philosophy 
and  psychology,  has,  with  his  usual  breadth  of  treatment, 
adopted  a  classification  which  does  in  a  great  measure  avoid 
the  use  of  these  words,  except  indeed  where  the  use  of  them 
admits  of  accurate  definition.  We  shall  avail  ourselves  of  this 
classification  in  our  future  remarks. 

Mr.  Spencer  subdivides  all  mental  states  into  volitions,  cog- 
nitions, and  feelings ;  and  the  first  of  these  subdivisions  may 
be  disposed  of  in  a  few  words.  "  Will,"  says  Mr.  Herbert 
Spencer,  "  is  a  simple  homogeneous  mental  state,  forming  the 
link  between  feeling  and  action,  and  not  admitting  of  sub- 
divisions." 

"  Cognitions,"  says  Mr.  Spencer,  "  are  those  modes  of  mind 
in  which  we  are  occupied  with  the  relations  that  subsist  among 
our  feelings."    They  are  divisible  into  four  great  sub-classes. 

(1)  "  Presentative  cognitions,  or  those  in  which  conscious- 
ness is  employed  in  localising  a  sensation  impressed  on  the 
organism." 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       481 

(2)  "  Presentative-representative  cognitions,  or  those  in 
which  consciousness  is  occupied  with  the  relations  between 
a  sensation  or  group  of  sensations  and  the  representations  of 
those  various  other  sensations  that  accompany  it  in  experience" 
(perceptions). 

(3)  "Representative  cognitions,  or  those  in  which  conscious- 
ness is  occupied  with  the  relations  among  ideas  or  represented 
sensations,  as  in  all  acts  of  recollection"  (concrete  ideas). 

(4)  "Re-representative  cognitions,  or  those  in  which  the  occu- 
pation of  consciousness  is  not  by  representation  of  special  rela- 
tions that  have  before  been  presented  to  consciousness,  but  those 
in  which  such  represented  special  relations  are  thought  of 
merely  as  comprehended  in  a  general  relation — those  in  which 
the  concrete  relations  once  experienced,  in  so  far  as  they  become 
objects  of  consciousness  at  all,  are  incidentally  represented  along 
with  the  abstract  relation  which  formulates  them"  (abstract 
ideas).  "  It  is  clear,"  Mr.  Spencer  adds,  "  that  the  process  of 
representation  is  carried  to  higher  stages  as  the  thought  becomes 
more  abstract." 

Feelings,  or  those  modes  of  mind  in  which  we  are  occupied, 
not  with  the  relations  subsisting  between  our  sentient  states, 
but  with  the  sentient  states  themselves,  are  divisible  into  four 
parallel  sub-classes. 

(1)  Presentative  feelings  are  those  in  which  a  corporeal  im- 
pression is  regarded  as  pleasure  or  pain  (sensations). 

(2)  Presentative-representative  feelings  are  those  in  which  a 
sensation  or  a  group  of  sensations  arouses  a  vast  group  of  repre- 
sented feelings  (emotions). 

(3)  Representative  feelings,  comprehending  the  ideas  of  the 
emotions  when  they  are  called  up,  apart  from  the  appropriate 
external  excitements,  such  as  the  emotions  excited  by  a  vivid 
description. 

(4)  Re-representative  feelings  are  those  more  complex  sen- 
tient states  that  are  less  the  direct  results  of  external  excite- 
ments than  the  indirect  or  reflex  results  of  them,  such  as  the 
love  of  property,  which  consists  of  the  represented  advantages 
of  possession  in  general,  which  is  not  made  up  of  certain  con- 
crete representations,  but  of  the  abstracts  of  many  concrete 
representations. 

FF 


482       ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

"The  classification,"  Mr.  Spencer  proceeds,  "here  roughly 
indicated,  and  capable  of  further  expansion,  will  be  found  in 
harmony  with  the  results  of  decided  analysis  aided  by  develop- 
ment. Whether  we  trace  mental  progression  through  the 
grades  of  the  animal  kingdom,  through  the  grades  of  mankind, 
or  through,  ithe  stages  of  individual  growth,  it  is  obvious  that 
the  advance,  alike  in  cognitions  and  feelings,  is,  and  must  be,  • 
from  the  presentative  to  the  more  and  more  remotely  represen- 
tative. It  is  undeniable  that  intelligence  ascends  from  those 
simple  perceptions  in  which  consciousness  is  occupied  in  locali- 
sing and  classifying  sensations,  to  perceptions  more  and  more 
compound,  to  simple  reasoning,  to  reasoning  more  and  more 
complex  and  abstract,  more  and  more  remote  from  sensation. 
And  in  the  evolution  of  feelings  there  is  a  parallel  series  of 
steps.  Simple  sensations  ;  sensations  combined  together ;  sen- 
sations combined  with  represented  sensations;  represented  sen- 
sations organised  into  groups  in  which  their  separate  characters 
are  very  much  igferged  ;  representations  of  those  representative 
groups  in  which  the  original  components  have  become  still  more 
vague.  In  both  cases  the  progress  has  necessarily  been  from 
the  simple  and  concrete  to  the  complex  and  abstract ;  and  as 
with  the  cognitions  so  with  the  feelings,  this  must  be  the  basis 
of  classification." 

It  is  not,  perhaps,  possible  in  the  present  state  of  our  know- 
ledge to  separate  the  cortex  of  the  brain  into  areas  exactly 
corresponding  to  the  various  subdivisions  of  Mr.  Herbert 
Spencer's  classifications.  The  cortex  may,  however,  be  sub- 
divided into  areas  which  will  correspond  with  the  leading 
features  of  this  classification. 

1.  The  cortex  of  the  brain  must  mainta-in  some  connection  with 
the  surface  of  the  body,  by  means  of  which  impressions  made 
on  the  latter  occasion  molecular  changes  in  the  former.  The 
parts  at  which  the  cortex  is  connected  with  the  centripetal 
system  of  nerves  may  be  called  sensory  inlets,  and  if  the  portion 
of  the  cortex  containing  these  inlets  can  be  isolated  from  the 
remaining  portions  of  the  cortex,  there  can  be  no  serious 
objections  to  calling  it  the  sensory  area  of  the  cortex.  And, 
indeed,  if  the  inlets  from  the  various  senses  can  be  more  or 
less    isolated    from    one    another,    each    may    be    called     a 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.       483 


sensory  centre.  We  have  already  seen  that  the  posterior  third 
of  the  posterior  division  of  the  internal  capsule  contains  cen- 
tripetal fibres  for  the  opposite  half  of  the  body,  and  that  these 
radiate  in  the  centrum  ovale  to  terminate  in  the  convolutions 
of  the  occipital  and  tempore- sphenoidal  lobes,  or  the  area  of 
the  cortex,  which  is  supplied  by  the  posterior  cerebral  artery. 

That  the  fibres  of  the  tract  which  ascends  in  the  external 
third  of  the  crusta  and  posterior  part  of  the  external  capsule 
are  sensory  has  been  proved  by  the  experiments  of  Veyssiere, 
and  confirmed  by  Carville  and  Duret,  Raymond,  and  others. 
Veyssiere  showed  that  section  of  the  posterior  part  of  the  in- 
ternal capsule  lying  between  the  lenticular  nucleus  and  optic 
thalamus  was  followed  by  hemianaesthesia  of  the  opposite  side 
of  the  body. 

Fig.  228. 


'        L 


Fig.  228  (After  Carville  and  Duret).  Transverse  Section  of  the  Brain  of  a  Dog  on  a 
level  with  the  Corpora  Albicantia. — O,  O,  Optic  thalami;  S,  S,  Caudate  nuclei ; 
L,  L,  Lenticular  nuclei ;  P,  P,  Posterior  region  of  the  internal  capsule  ; 
X,  Section  of  the  posterior  part  of  the  internal  capsule  determining  hemi- 
anajsthesia  ;  A,  A,  Cornu  Ammonis. 

2.  The  cortex  of  the  brain  must  be  connected  with  the 
muscular  system,  in  order  that  the  reactions  of  the  organism 
upon  its  environment  may  be  regulated  in  correspondence  with 
the  impressions  made  upon  it.  The  parts  at  which  the  cortex 
is  connected  with  centrifugal  fibres  may  be  called  motor  outlets, 
and  if  the  portion  of  the  cortex  which  contains  these  can  be 
isolated  from  the  remaining  portions  of  the  cortex  it  may  be 
called  the  'motor  area.  And  if  the  motor  outlet  for  a  particular 
movement  can  be  isolated  from  the  outlets  for  other  movements 
there  can  be  no  great  harm  in  calling  it  a  motor  centre. 


484       ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 

A  cortical  motor  centre  then  constitutes  the  link  between 
cortical  activity  on  the  one  side,  and  voluntary  muscular  con- 
tractions on  the  other ;  and  volition  being  the  link  between 
feeling  and  action,  the  cortical  motor  centres  may  be  regarded 
as  the  structural  counterparts  of  volitions. 

We  have  already  seen  that  the  pyramidal  tract  contains  the 

centrifugal  fibres  from  the  cortex  of  the  brain,  and  this  has  also 

been  determined  experimentally  by  Veyssiere,  who  found  that 

section  of  the  anterior  two-thirds  of  the  internal  capsule  was 

followed  by  hemiplegia  of  the  opposite  side,  unaccompanied  by 

sensory  paralysis. 

Fig.  229. 


Fig.  229  (After  Carville  and  Duret).  Transverse  Section  of  the  Brain  of  the  Dog, 
fire  millimetres  in  front  of  the  optic  commissure.— S,  S,  The  caudate  nuclei  of 
the  corpora  striata  ;  P,  P,  Peduncular  fibres  (the  internal  capsule)  ;  L,  Lenti- 
cular nucleus ;  R,  Stylet,  by  means  of  which  Veyssiere  produced  section  of  the 
internal  capsule  at  (x). 

But  the  pyramidal  tract  is  not,  according  to  most  anatomists,  the  only- 
outlet  from  the  cortex  of  the  brain.  Leaving  out  of  account  the  centri- 
fugal fibres  which  probably  connect  the  cortex  of  the  cerebrum  with  the 
eerebellmn,  there  still  remain  the  fibres  which  connect  the  cortex  of  the 
cerebrum  with  the  central  grey  tube  through  the  intermediation  of  the 
corpus  striatum.  The  cortical  actions  which  are  regulated  through  the 
corpus  striatum  and  pyramidal  tract  are  often,  although  not  always,  an- 
tagonistic to  one  another.  The  excitation  of  the  cortex  which  is  the  cor- 
relative of  feeling,  whether  the  latter  be  pleasurable  or  painful,  always 
tends  to  find  a  vent  in  immediate  action,  while  a  great  portion  of  our 
voluntary  efforts  are  directed  to  restrain  action,  and  to  postpone  the  im- 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.        485 

mediate  gratification  of  the  feelings  in  order  to  accomplish  remote  ends. 
Excitation,  for  instance,  of  the  cells  in  the  cortex  which  are  in  immediate 
contact  with  the  terminations  of  the  centripetal  nerves  in  the  sixmmits  of 
the  convolutions  of  the  posterior  area  of  the  cortex  tends  to  be  conducted 
immediately  outwards  along  the  centrifugal  fibres  which  connect  these 
convolutions  with  the  corpus  striatum.  If  these  excitations  are  conducted 
at  once  outwards,  they  give  rise  to  movements  which  have  been  named 
sensori-motor ;  but  if  the  excitations,  instead  of  being  conducted  at  once  . 
outwards,  pass  from  the  cells  in  connection  with  the  termination  of  one 
bundle  of  centripetal  fibres  (vision)  to  those  in  connection  with  another 
bundle  (tactile),  so  that  the  relation  between  the  two  feehngs  comes 
into  prominence,  then  a  presentative  cognition  is  formed.  When, 
for  instance,  the  centripetal  impulse  received  in  a  convolution  from  the 
irritation  caused  by  a  thorn  in  the  finger  is  brought  into  connection  with 
the  impressions  received  through  the  optic  and  other  centripetal  nerves, 
and  which,  on  reaching  the  cortex,  becomes  the  correlative  of  the  con- 
sciousness of  the  finger  itself,  then  a  cognition  of  the  relationship  of  pre- 
sentative feeling  is  formed.  Now,  a  presentative  cognition  does  not 
usually,  Hke  a  presentative  feehng,  immediately  result  in  action.  The 
excitation  expends  itself  in  the  former  in  producing  excitation  of  other 
groups  of  cells  in  the  cortex,  the  transition  from  one  group  to  another 
giving  rise  to  other  presentative  and  representative  cognitions,  vmtil  finally 
the  motor  area  is  reached,  and  the  excitation  passes  out  along  the  pyramidal 
fibres.  Subjectively  considered,  the  cognition  of  the  thorn  and  finger  would 
call  up  other  cognitions  connected  with  these  by  previous  experiences,  as 
that  of  a  pin,  and  probably  the  highly  representative  cognitions  of  the 
general  properties  of  the  lever,  imtil  finally  the  pin  is  voluntarily  grasped 
and  rightly  appUed  for  the  removal  of  the  thorn.  This  action  is  very 
diflferent  from  that  which  impels  a  dog  to  lick  with  his  tongue  the  foot  in 
which  a  thorn  is  lodged.  The  latter  is  a  sensori-motor  or  doubly  compound 
reflex  action,  and  in  immediate  relation  with  the  cortical  excitation  which 
causes  the  feeling  of  pain,  while  the  former  resiilts  from  a  series  of  com- 
plex cortical  excitations,  some  of  which  check  the  tendency  to  immediate 
action,  until  by-and-by  complex  actions  result  which  are  guided  by  wide 
experience  and  adapted  to  remote  ends.  The  movements  which  result 
immediately  from  the  feelings  have  been  called  sensori-motor,  percipio- 
motor,  and  ideo-motor,  on  the  supposition  that  they  occurred  in  response 
to  the  cognitions ;  but  it  would  be  better  to  call  the  movements  which 
result  from  a  presented  feeling  a  doubly  compound  reflex  action,  that  from 
a  presentative-representative  feeling  a  trebly  compound  reflex  action,  and 
that  from  a  representative  feeling  a  quadruply  compound  reflex  action, 
and  so  on  in  an  ascending  scale,  according  to  the  degree  of  the  complexity 
of  the  feehng.  When,  however,  a  series  of  cognitions  intervene  in  the 
mental  operations  between  the  feeling  which  prompts  a  movement  and 
the  movement  itself,  the  resulting  jnuscular  adjustment  is  a  voluntary 
one,  and  is  regulated  through  the  pyramidal  fibres.     When,  for  instance, 


486       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

Leverrier,  prompted  by  the  highly  representative  feeling  of  a  desire  for 
discovery,  directed  his  telescope  to  a  certain  spot  in  the  heavens,  and  dis- 
covered Neptune,  the  requisite  muscular  adjustments  necessary  for  carry- 
ing out  this  action  were  preceded  in  his  mind  by  a  long  series  of  involved 
and  highly  representative  cognitions;  and  these  muscular  adjustments 
themselves  were,  to  a  large  extent,  voluntary. 

■  3.  The  region  of  the  cortex  supplied  by  the  anterior  cerebral 
artery  still  remains  to  be  connected  with  some  kind  of  mental 
activity.  We  have  seen  that  the  area  supplied  by  the  posterior 
cerebral  artery  is  the  sensory  area,  and  consequently  excitation 
of  this  area  is  the  correlative  of  the  presentative  and  presenta- 
tive-representative  cognitions  and  feelings,  while  excitation  of 
the  area  supplied  by  the  middle  cerebral  artery  is  the  cor- 
relative of  volition.  Excitation  of  the  cortical  area  supplied  by 
the  anterior  cerebral  artery  is  the  correlative  again  of  the 
representative  and  re-representative  cognitions  and  feelings.  It 
is  somewhat  difficult  to  find  a  name  which  will  be  expressive  of 
the  functions  of  this  area,  and  if  we  consent  to  call  it  the 
ideational  area,  it  must  be  remembered  that  it  is  no  less  likely 
to  be  the  anatomical  substratum  of  the  higher  emotions  than 
of  the  higher  intellectual  operations. 

§  686.  Anatomical  Substratum  of  Consciousness. — It  is  well 
recognised  that  a  large  number  of  psychical  actions  may  take 
place  in  an  unconscious  manner.  Leaving  out  of  consideration 
the  phenomena  of  dreaming  and  somnambulism,  we  may  in- 
stance such  a  familiar  fact  as  that  a  man  may  read  aloud  whole 
pages  of  a  book  while  his  mind  is  engaged  in  solving  a  difficult 
problem,  and  he  is  wholly  unconscious  of  what  he  is  saying,  yet 
the  muscular  movements  engaged  in  reading  are  co-ordinated 
in  the  cortex  of  the  cerebrum.  If,  under  these  circumstances,  the 
eye  falls  on  an  unusual  word,  consciousness  is  directed  to  it  for 
a  moment,  and  the  reading  may  then  go  on  unconsciously  as 
before.  It  would  therefore  appear  that  impressions  which  have 
been  frequently  repeated  in  experience  may  pass  up  to  the  cortex 
and  give  rise  to  complicated  motor  impulses  from  the  cortex 
without  being  attended  by  consciousness ;  but  that  when  the 
impressions  made  on  the  sensory  organ  present  an  unusual 
combination,  consciousness  is  aroused.     Unusual  combinations 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.       487 

of  sensory  impressions  are,  therefore,  probably  conducted  to 
and  through  the  cortex  in  channels  which  are  only  partially 
open,  while  the  habitual  combinations  pass  in  channels 
which  are  open  and  well  defined.  In  intellectual  efforts  the 
highest  consciousness  is  aroused  when  the  mind  is  contem- 
plating new  combinations  of  presentative  and  representative 
impressions,  or,  to  translate  this  into  the  language  of  physics, 
when  the  organism  is  adjusting  itself  to  new  combinations  of 
circumstances  and  events.  In  other  words,  the  highest  intel- 
lectual consciousness  is  aroused  during  the  time  that  a  new 
organisation  in  the  cortex  of  the  brain  is  being  superadded  to 
the  existing  one,  while  excitation  of  the  portion  of  the  cortex 
which  is  already  thoroughly  organised  is  attended  by  little 
or  no  consciousness. 

It  cannot  be  supposed  that  the  large  cells,  with  the  distinct 
processes  and  definite  connections  found  in  the  internal  division 
of  the  third  layer  of  the  cortex,  will  readily  undergo  structural 
changes  in  the  healthy  adult,  and  it  is  much  more  probable 
that  any  new  alteration  of  structure  in  the  cortex  will  proceed 
from  the  small  cells  of  the  external  layers  of  the  cortex.  The 
first  layer  may  probably  be  regarded  as  an  embryonic  layer 
without  any  active  nerve  functions,  and  consequently  the  second 
layer  and  external  portion  of  the  third  layer  of  the  cortex,  the 
cells  of  which  do  not  possess  definite  connections  with  one 
another  or  with  nerve  fibres,  must  be  regarded  as  the  areas, 
excitation  of  which  is  attended  by  the  highest  consciousness. 

Experiments  on  animals  have  proved,  as  we  have  seen,  that 
the  fibres  which  pass  through  the  posterior  third  of  the  posterior 
division  of  the  internal  capsule  are  sensory,  but  the  sensory  area 
of  the  cortex  is  also  connected  with  the  periphery,  through  the 
optic  thalamus  and  its  radiating  fibres.  It  is  probable  that 
impressions  which  have  been  frequently  repeated  in  experience 
pass  through  the  optic  thalamus  and  its  radiating  fibres,  and 
that  they  give  rise  to  little  or  no  consciousness  on  reaching 
the  cortex.  It  may  be  presumed,  on  the  other  hand,  that 
unusual  combinations  of  impressions  are  conducted  through  the 
posterior  fibres  of  the  internal  capsule,  and  give  rise  on  reaching 
the  cortex  to  distinct  consciousness. 


488       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

§  687.  Experimental  Determination  of  the  Functions  of 

the  Cortex  of  the  Brain. 

1.  Motor  Centres. 

Experiments  hy  Stimulation.  —When  the  cerebrum  is  removed  slice  by 
slice  there  is  a  gradual  loss  of  intelligence  and  volition,  and  consequently 
Flourens,  who  conducted  these  experiments,  concluded  that  the  brain 
acted,  as  a  whole,  without  any  special  functions  being  assigned  to  special 
parts.  Hughlings-Jackson,  however,  drew  attention  to  the  fact  that  focal 
disease  of  the  cortex  of  the  brain  may  occasion  epileptiform  convulsions, 
localised  to  particular  groups  of  muscles.  Hitzig  and  Fritsch  showed  that 
the  local  application  of  the  galvanic  current  to  particular  parts  of  the 
cerebral  convolutions  gives  rise  to  definite  movements  of  various  groups  of 
muscles.  These  experiments  were  extended  and  rendered  more  definite 
by  Terrier,  who  used  the  faradic  instead  of  the  galvanic  current  as  a 
means  of  stimulation.  The  motor  centres  as  determined  by  Terrier  in 
the  monkey  are  represented  in  Figs.  230  and  231,  while  the  corresponding 
parts  in  the  human  brain  are  shown  in  Figs.  232  and  233. 

Fig.  230. 


Fig.  230  (After  Terrier).     The  Left  Hemisphere  of  the  Monkey. 


Burdon-Sanderson  states  that  the  motor  reacti  ons  to  cortical  stimulation 
are  not  prevented  from  taking  place  by  a  horizontal  incision  carried  some 
distance  from  the  surface.  This  simply  shows  that  a  faradic  current 
applied  to  the  surface  of  the  brain  is  conducted  into  the  centrum  ovale 
and  stimulates  the  ends  of  the  divided  pyramidal  fibres,  but  it  does  not 
show  that  the  cortex  is  non-excitable. 

Burdon-Sanderson  also  found  that  local  stimulation  of  the  white  matter 
immediately  surrounding  the  corpus  striatum  produces  localised  move- 
ments similar  to  those  caused  by  stimulation  of  the  corresponding  cerebral 
surface.  This  experiment,  like  the  last,  shows  that  the  fibres  of  the 
pyramidal  tract  are  excitable,  but  it  proves  nothing  with  regard  to  the 
excitability  or  non-excitability  of  the  cortex.     If  the  motor  area  of  the 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       489 

cortex  be  removed,  excitation  of  the  subjacent  white  substance  causes  the 
same  movements  as  excitation  of  the  motor  centre  itself.  In  such  a  case 
the  ends  of  the  fibres  of  the  pyramidal  tract  which  issued  from  the  motor 
centre  are  now  exposed,  and  excitation  of  them  causes  the  same  kind 
of  motor  reaction  as  that  caused  by  excitation  of  the  motor  centre 
itself.  If  the  animal,  however,  survive  the  operation,  the  pyramidal  fibres 
undergo  secondary  descending  degeneration,  and  excitation  of  the  scar  or 

Fia.  231. 


Fig.  231  (After  Ferrier).     Up2nr  Sin-face  of  the  Hemisphere  of  the  Monkey. 


1,  Advance  of  the  opposite  leg  as  in  walking. 

2,  Complex  movements  of  the  thigh,  leg,  and  foot,  with  adapted  movements  of 

the  trunk. 

3,  Movements  of  the  tail. 

4,  Retraction  and  adduction  of  the  opposite  fore  limb. 

5,  Extension  forward  of  the  opposite  arm  and  hand,  as  if  to  reach  or  touch 

something  in  front. 
Circles  (a),  (6),  (c),  (d),  Individual  and  combined  movements  of  the  fingers  and 
wrists,  ending  in  clenching  of  the  fist. 

6,  Supination  and  flexion  of  the  forearm,  by  which  the  hand  is  raised  towards 

the  mouth. 

7,  Action  of  the  zygomatics,  by  which  the  angle  of  the  mouth  is  retracted  and 

elevated. 

8,  Elevation  of  the  ala  of  the  nose  and  upper  lip,  with  depression  of  the  lower 

lip,  so  as  to  expose  the  canine  teeth  on  the  opposite  side. 

9,  Opening  of  the  mouth  with  protrusion  of  the  tongue. 

10,  Opening  of  the  mouth  with  retraction  of  the  tongue. 

11,  Retraction  of  the  angle  of  the  mouth. 

12,  Eyes  opening  widely,  pupils  dilating,  head  and  eyes  turning  towards  the 

opposite  side. 
13  and  13',  Eyeballs  moving  to  the  opposite  side.     Pupils  generally  contracting. 

14,  Sudden  retraction  of  the  opposite  ear. 

15,  Subiculum  cornu  Ammonis.    Torsion  of  the  lip  and  nostril  on  the  same  side. 


490       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

its  neighbourhood  no  longer  produces  the  particular  movements  charac- 
teristic of  the  destroyed  area  (Albertoni  and  Michieli). 

Experiments  hy  Destxuction  of  Portions    of  the  Cortex. — It  has  been 
observed   that  removal   or   destruction   of  a   motor   centre  is  followed 

Fig.  232. 


Figs.  232  and  233  (After  Ferrier).    Side  and  Upper  Views  of  the  Brain  of  Man. 

The  figures  are  constructed  by  marking  on  the  brain  of  man,  in  their  respective 
situations,  the  motor  areas  of  the  brain  of  the  monkey  as  determined  by  experiment, 
and  the  description  of  the  effects  of  stimulating  the  various  areas  refers  to  the  brain 
of  the  monkey. 

1  (On  the  postero-parietal  lobule),  Advance  of  the  opposite  hind  hmb  as  in 
walking. 

2,  3,  4  (Around  the  upper  extremity  of  the  fissure  of  Rolando^,  Complex  move- 
ments of  the  opposite  leg  and  arm,  and  of  the  trunk,  as  in  swimming. 

a,  b,  c,  d  (On  the  ascending  parietal  convolution),  Individual  and  combined 
movements  of  the  fingers  and  wrist  of  the  opposite  hand.  Prehensile 
movements. 

5  (At  the  posterior  extremity  of  the  superior  frontal  convolution),  Extension 

forward  of  the  opposite  arm  and  hand. 

6  (On  the  upper  part  of  the  ascending  frontal  convolution),  Supination  and 

flexion  of  the  opposite  forearm. 

7  (On  the  median  portion  of  the  ascending  frontal  convolution),  Retraction  and 

elevation  of  the  opposite  angle  of  the  mouth  by  means  of  the  zygomatic 
muscles. 

8  (Lower  down  on  the  same  convolution),  Elevation  of  the  ala  nasi  and  upper 

lip  with  depression  of  the  lower  lip,  on  the  opposite  side. 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.        491 

by  inability  to  execute  the  movements  assigned  to  the  area  (Hitzig, 
Ferrier),  but  it  has  subsequently  been  found  that  the  paralytic  symptoms 
disappear  when  the  animal  operated  upon  survives  some  days  (Nothnagel, 
Hermann,  Goltz).     Hermann  removed  cortical  motor  centres  from  dogs, 

Fig.  233. 


9,  10  (At  the  inferior  extremity  of  the  ascending  frontal  and  posterior  extremity 
of  the  third  frontal  convolution),  Opening  of  the  mouth  with  (9)  protrusion 
and  (10)  retraction  of  the  tongue.     Region  of  Aphasia. 

11  (At  the  inferior  extremity  of  the  ascending  parietal  convolution),  Retraction 

of  the  opposite  angle  of  the  mouth,  the  head  turned  slightly  to  one  side. 

12  (On  the  posterior  portions  of  the  superior  and  middle  frontal  convolutions). 

Eyes  opening  widely,  pupils  dilating,  and  the  head  and  eyes  turning 
towards  the  opposite  side. 

13, 13'  (On  the  supra-marginal  lobule  and  angular  gyrus),  The  eyes  moving 
towards  the  opposite  side  with  an  upward  (13)  or  downward  (13')  devia- 
tion.    Pupils  generally  contracting.     (Centre  of  vision. ) 

14  (On  _  the  infra-marginal  or  superior  temporo-sphenoidal  convolution). 
Pricking  up  of  the  opposite  ear,  head  and  eyes  turning  to  the  opposite 
side,  and  pupils  dilating  largely.     (Centre  of  hearing.) 

Ferrier  moreover  places  the  centres  of  taste  and  smell  at  the  extremity  of  the 
temporo-sphenoidal  lobe,  and  that  of  touch  in  the  gyrus  uncinatus  and  hippo- 
campus major. 


492       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

and  found  that  the  paralysis,  which  immediately  followed  the  operation, 
disappeared  in  a  few  days.  These  results  were  afterwards  confirmed  by 
Carville  and  Duret,  who  also  found  that  the  restoration  of  motor  power 
could  not  have  been  due  to  the  corresponding  centre  of  the  opposite 
hemisphere,  inasmuch  as  subsequent  destruction  of  the  latter  produced 
the  usual  paralysis  on  the  side  opposite  to  the  lesion,  but  did  not  cause  a 
repetition  of  the  paralysis  on  the  side  opposite  to  the  first  lesion.  These 
authors  suppose  that  portions  of  the  same  hemisphere  took  up  the  func- 
tions of  the  destroyed  centre. 

Fig.  234. 


Fig.  234  (After  Broca  and  Gomier).  External  Convex  Surface  of  the  Brain  of  the 
Adult  Monkey. — Fissures :  R,  Fissure  of  Rolando  :  S/,  Fissure  of  Sylvius  ;  pf, 
Parallel  fissure  ;  pof,  External  perpendicular  or  parieto-occipital  fissure  ;  pcf, 
Prae-central  fissure.  Convolutions:  A,  Ascending  frontal  convolution;  B, 
Ascending  parietal  convolution;  Fi,  Fa,  Fa,  First,  second,  and  third  frontal 
convolutions  ;  ag,  Angular  gyrus  ;  img,  Infra-marginal  gyrus ;  hi,  Horizontal 
lobule  ;  ol,  Occipital  lobe.  Motor  Centres  :  1,  Movements  for  rotation  of  head 
and  neck ;  2,  Movements  of  muscles  of  the  face  ;  3,  Movements  of  the  tongue 
and  jaws;  4,  Movements  of  anterior  extremity;  5,  Movements  of  posterior 
extremity ;  6,  Movements  of  the  ocular  muscles ;  7,  Movements  in  relation 
with  sense  of  hearing. 


Goltz  removed  parts  of  the  cerebral  surface  by  washing  the  nervous 
substance  away  by  a  stream  of  water,  and  he  came  to  the  conclusion  that 
the  paralytic  phenomena  did  not  depend  so  much  upon  the  locality  as  the 
extent  of  the  injury.  He  also  found  that  the  paralysis  disappeared  in  a 
short  time,  whatever  might  be  the  portion  of  brain  removed.  He  was  able 
in  one  case  to  remove  the  greater  part  of  one  hemisphere,  and  yet  recovery 
of  motor  power  took  place,  clumsiness  in  the  execution  of  certain  move- 
ments alone  remaining ;  this  Goltz  attributed  to  a  deficiency  of  tactile 
sensibility.  He  thinks  that  the  paralytic  phenomena  are  caused  by  an 
inhibitory  action  produced  by  the  injury  on  lower  centres,  similar  to  the 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       493 

temporary  paralysis  of  the  automatic  centres  in  the  lumbar  portion  of  the 
spinal  cord  produced  by  section  in  the  dorsal  region. 

But  examples  of  a  localised  destroying  lesion  of  the  cortex  of  the  brain 
in  man  have  now  multiplied  to  such  an  extent  that  there  is  no  room  for 
doubt  with  regard  to  the  main  symptoms  caused  by  them,  whatever  may 
be  the  interpretation.  When  a  patient  has  been  unable  to  move  his  right 
arm  and  hand  for  months,  and  when  after  death  a  destructive  lesion  of 
the  cortex  of  the  opposite  hemisphere  is  observed  strictly  limited  to  the 
middle  of  the  ascending  frontal  and  parietal  convolutions,  and  when  cases 
of  this  nature  occur  with  sufficient  frequency  to  show  that  the  connection 
between  the  lesion  and  symptoms  during  life  is  not  accidental,  it  is  idle 
for  any  physiologist  to  deny  that  the  paralysis  was  due  to  destruction 
of  the  cortex  in  that  area,  inasmuch  as  only  temporary  paralysis  would  be 
caused  by  a  similar  lesion  in  the  dog.  The  fact  that  paralysis  following 
cortical  lesions  in  the  dog  is  only  temporary  shows  that  diflferences  must 
exist  with  regard  to  the  relation  which  obtains  between  the  highest  nerve 
centres  and  muscular  movements  in  man  and  the  dog  respectively. 
And  it  is  not  difficult  to  point  out  where  some  of  these  differences  lie. 

Fig.  235. 


.-pcf 


Fio.  285.  External  Convex  Surface  of  the  Human  Brain. — Fissures :  R,  Fissure  of 
Rolando ;  S/,  Fissure  of  Sylvius ;  p/,  Parallel  fissure ;  ipf,  Interparietal  fissure ; 
pof,  External  parieto-occipital  fissure.  Convolutions  and  Lobules :  A,  Ascending 
frontal;  B,  Ascending  parietal  convolutions;  Fi,  Fa,  Fs,  First,  second,  and 
third  frontal  convolutions;  Pi,  Superior  parietal  lobule;  Pa,  Supra-marginal 
gyrus  ;  Ps,  Angular  gyrus  ;  Oi,  O'^,  Os,  First,  second,  and  third  occipital  con- 
volutions ;  Ti,  T2,  T3,  First,  second,  and  third  temporo-sphenoidal  convolu- 
tions. Motor  Centres  :  1,  Movements  for  rotation  of  head  and  neck  ;  2,  Move- 
ments of  the  upper  facial  muscles  ;  2',  Movements  of  the  lower  facial  muscles  ; 
3,  Movements  of  the  tongue  and  jaws  ;  4,  Movements  of  superior  extremity ; 
5,  Movements  of  inferior  extremity ;  6,  Movements  of  the  ocular  muscles  ;  7, 
Movements  in  relation  with  the  sense  of  hearing. 


494       ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 

We  have  already  aeen  that  paralysis  of  the  external  rectus  muscle  of  the 
one  side  and  of  the  internal  of  the  other  occurs  in  most  cases  of  sudden 
hemiplegia  in  man,  causing  a  conjugate  deviation  of  the  eyes  away  from 
the  paralysed  side.  This  paralysis  disappears  in  a  few  days,  and  is 
almost  exactly  similar  to  what  occurs  in  the  paralyses  of  cortical  lesions 
caused  in  the  dog.  And  even  injury  to  the  deep-seated  parts  of  the 
brain  in  the  dog,  such  as  the  crus  cerebri,  does  not  cause  a  hemiplegia 
at  all  comparable  to  the  hemiplegia  which  occurs  in  man.  In  lesion 
of  the  right  crus  cerebri  in  the  dog  there  is  only  a  very  partial  hemi- 
plegia. When  standing  the  animal  carries  his  body  towards  the  right, 
his  eyes  are  directed  to  the  right,  and  his  head  is  also  rotated  to  the  right, 
and  if  the  animal  move  he  goes  round  in  a  circle  after  his  tail  (Broadbent). 
It  would  not  be  more  preposterous  to  tell  us  that  because  injury  of  the 
crus  cerebri  causes  a  mouvement  de  manege  in  the  dog  it  cannot  therefore 
cause  hemiplegia  in  man,  as  to  say  that  because  rapid  recovery  from  the 
paralysis  caused  by  cortical  lesions  takes  place  in  the  dog  the  affections 
caused  by  similar  lesions  in  man  is  not  due  to  the  destruction  of  a 
cortical  centre.  The  disappearance  of  paralysis  of  the  limbs  in  the  dog 
corresponds  exactly  to  the  disappearance  of  conjugate  deviation  of  the 
eyes  in  man,  and  the  explanation  which  suffices  for  the  one  will  probably 
suffice  for  the  other  (§  90).  But  even  Goltz  admits  that  some  movements 
in  the  dog  become  more  or  less  permanently  paralysed.  For  instance,  he 
may  use  his  forepaw  to  drag  bones  and  other  morsels  of  food  from  under 
a  table,  and  he  may  also  be  taught  to  perform  special  tricks  with  his  paws  ; 
all  such  special  movements  become  more  or  less  permanently  lost  after 
portions  of  the  cortex  have  been  removed.  This  shows  that  the  purely 
voluntary  actions  are  more  or  less  permanently  lost,  while  paralysis  of 
the  automatic  actions  concerned  in  ordinary  locomotion  rapidly  disappears. 
Goltz  found  that  the  animals  operated  on  could  after  a  time  be  trained 
or  educated  to  perform  special  actions  with  their  paws,  a  fact  which  shows 
that  a  new  organisation  takes  place  more  readily  in  the  brain  of  the  dog 
than  in  that  of  man,  but  it  is  quite  probable  that  new  structural  arrange- 
ments may  also  take  place  to  a  certain  extent  in  the  brain  of  man  aftej 
partial  injury. 

2.  Sensory  Centres. 

It  has  already  been  seen  that  the  centripetal  fibres  terminate  amongst 
the  cells  of  the  second  and  third  layers  of  tlie  cortex  without  forming  any 
direct  connection  with  them,  while  the  fibres  of  the  pyramidal  tract  take 
origin  in  the  axis-cylinder  processes  of  the  giant-cells  of  the  internal 
portion  of  the  third  layer.  It  may,  therefore,  be  suspected  that  the  cen- 
tripetal currents  will  pass  in  a  much  more  diffused  manner  through  the 
cortex  than  the  centrifugal,  just  as  it  is  found  that  the  former  pass  in  a 
more  diffused  manner  through  the  spinal  cord  than  the  latter.  It  is  not 
therefore  likely  that  the  sensory  inlets  are  as  definitely  localised  as  the 
motor  outlets. 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.        495 

Experiments  hy  Stimulation. — On  stimulating  the  angular  gyrus 
Ferrier  obtained  various  movements  of  the  eye  and  associated  move- 
ments of  the  head,  and  he  regarded  the  phenomena  observed  as 
being  "  merely  reflex  movements  on  the  excitation  of  subjective  visual 
sensation."  He,  therefore,  concluded  that  the  angular  gyrus  and  sur- 
rounding grey  matter  constituted  the  centre  of  vision.  On  somewhat 
similar  grounds  he  placed  the  auditory  centre  in  the  superior  temporo- 
sphenoidal  convolution,  the  centres  of  taste  and  smell  at  the  extremity  of 
the  temporo-sphenoidal  lobe,  and  that  of  touch  in  the  gyrus  unciuatus 
and  hippocampus  major.  But  these  experiments,  although  exceedingly 
interesting  and  important  as  being  the  first  to  break  ground  in  a  new- 
territory,  are  by  no  means  conclusive.  Dr.- Ferrier  himself,  indeed,  did  not 
rest  satisfied  with  them,  but  proceeded  to  verify  his  hypotheses  by  the 
extirpation  or  destruction  of  the  portions  of  the  cortex  which  he  supposed 
to  be  the  sensory  centres. 

Experiments  by  Extirpation  or  Destruction  of  Sensory  Centres. — The 
most  remarkable  result  obtained  by  Ferrier  in  his  first  experiments 
was  afibrded  by  destruction  of  the  angular  gyrus.  When  the  angular  gyrus 
of  the  left  hemisphere  was  destroyed,  it  was  found  that  the  animal  was 
blind  on  the  right  eye  soon  after  the  operation,  but  recovered  sight  com- 
pletely on  the  following  day.  In  another  case  the  angular  gyri  of  both 
hemispheres  were  destroyed  and  the  animal  became  completely  blind  in 
both  eyes.     In  no  case  was  any  motor  paralysis  observed. 

The  admitted  objections  to  these  experiments  are  that  Ferrier  did  not 
keep  his  animals  alive  a  sufficiently  long  time  to  ascertain  if  a  return  of 
vision  occurred.  Goltz  found  in  his  experiments  that  when  a  considerable 
portion  of  the  cortex  of  the  brain  was  removed  the  animals,  although  not 
blind,  manifested  a  peculiar  imperfection  of  vision.  The  animal  operated 
upon  could  use  his  sight  in  avoiding  obstacles,  but  often  failed  to  recognise 
his  food,  and  appeared  quite  indififerent  when  threatened  with  the  whip. 
He  also  found  that  recovery  from  this  condition  was  possible,  at  least  to  a 
considerable  extent,  by  means  of  educational  exercises. 

Munk  believes  again  in  the  existence  of  a  "  visual  area,"  situated  in 
the  occipital  lobes,  and  of  much  larger  extent  than  that  of  Ferrier.  He 
maintains  that  removal  of  this  area  causes  blindness,  and  that  extirpa- 
tion of  small  portions  of  it  gives  rise  to  blindness  of  localised  areas  of 
the  retina.  He  believes  that  there  are  three  visual  spheres  in  the  cortex 
of  the  occipital  lobe  corresponding  to  three  visual  areas  in  the  retina. 
The  external  part  of  the  retina  of  the  left  eye  is  connected  with  the 
external  part  of  the  cortical  visual  centre  in  the  left  hemisphere,  while 
the  internal  and  central  portions  of  the  retina  of  the  right  eye  are  respec- 
tively connected  with  the  internal  and  central  portions  of  the  visual 
centre  of  the  opposite  or  left  hemisphere.  He  also  thinks  that  the 
upper  part  of  the  retina  is  connected  with  the  front,  and  the  lower  part 
with  the  posterior  aspect  of  the  visual  centre  of  the  opposite  side. 
Removal  of  both  visual  centres  causes,  according  to  this  observer,  complete 


496       ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

or  absolute  blindness.  Partial  removal  of  these  areas  on  the  other  hand 
gives  rise  to  the  visual  defect  called  attention  to  by  Goltz,  in  which  the 
animal  can  see  and  avoid  objects,  but  does  not  recognise  his  food  as  such. 
This  Munk  calls  psychical  blindness  (Seelenlahmungen,  Seelenblindheit). 
He  finds  that  after  a  time  the  animals  recover  from  psychical  blindness, 
provided  the  whole  visual  area  be  not  removed.  He  thinks  that  the 
recovery  is  due  to  a  process  by  which  there  is  a  deposition  of  new  visual 
experiences  in  the  rest  of  the  visual  area.  The  physical  part  of  the 
restoration  might  probably  be  spoken  of  with  greater  justice  as  the 
formation  of  new  structural  arrangements  in  the  visual  areas.  Munk 
describes  an  auditory  area,  which  however  differs  from  that  of  Ferrier,  and 
he  regards  the  whole  front  part  of  the  brain  as  forming  a  large  "sensory" 
area,  in  which  separate  sensory  centres  may  be  distinguished. 


Fig.  236. 


Fig.  236  (After  Munk).  Upper  Surface  of  the  Brain  of  pie  Monkey.— Sensory  Areas  : 
A,  of  the  eyes ;  B,  of  the  ears ;  C,  of  the  sensibility  of  the  lower  extremity ; 
D,  Anterior  extremity ;  E,  Head  ;  F,  Ocular  muscular  apparatus  ;  G,  Region 
of  ears;  H,  Neck;  I,  Body. 

An  elaborate  paper  on  the  cerebral  visual  centres  was  read  before 
the  physiological  section  at  the  meeting  of  the  British  Medical  Association, 
at  Cambridge,  in  August  last,  by  Professors  Ferrier  and  Gerald  F.  Yeo. 
Large  portions  of  the  brains  of  monkeys  were  removed,  the  operations 
being  conducted  antiseptically,  so  that  there  was  a  total  absence  of 
encephalitis.    The  following  is  an  abstract  of  the  chief  results  obtained : — 

1.  Removal  of  both  occipital  lobes  did  not  cause  any  recognisable  dis- 
turbance of  vision,  or  other  bodily  or  mental  derangement,  provided  the 
lesion  did  not  extend  beyond  the  parieto-occipital  fissure. 

2,  Complete  destruction  of  one  angular  gyrus  causes  temporary  loss  of 
vision  of  one  eye,  lasting  only  a  few  hours.     The  restoration  of  vision  is 


J 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.       497 

not  due  to  the  integrity  of  the  other  angular  gyrus.  If  both  angular  gyri 
be  destroyed  simultaneously  total  blindness  ensues  in  both  eyes,  but  does 
not  last  more  than  three  days,  although  vision  may  be  impaired  for 
months.  If  the  angular  gyri  be  destroyed  successively/,  several  weeks 
elapsing  between  the  operations,  the  animal  sees  quite  well  with  both  eyes 
in  a  few  hours. 

3.  Simultaneous  destruction  of  the  angular  gyrus  and  occipital  lobe  on 
one  side  causes  evident  loss  of  vision  in  both  eyes  towards  the  side  oppo- 
site the  lesion  (hemiopia),  but  recovery  from  this  condition  takes  place  at 
the  end  of  a  week. 

4.  Destruction  of  the  left  angular  gyrus  (recovery),  and  subsequently  of 
the  right  angular  gyrus  and  occipital  lobe,  produces  left  hemiopia,  from 
which  the  animal  recovers  in  a  fortnight. 

5.  Destruction  of  both  occipital  lobes,  followed  after  a  time  by  destruc- 
tion of  the  left  angular  gyrus,  causes  transient  blindness  followed  by 
indistinctness  of  vision  of  right  eye,  with  subsequent  complete  recovery. 

6.  Destruction  of  both  angular  gyri  and  occipital  lobes  causes  total  and 
permanent  blindness  in  both  eyes,  without  any  impairment  of  the  other 
senses  or  of  motor  power. 

3.  Prce-frontal  or  Ideational  Area  of  the  Cortex. 

Experiments  by  Stimulation. — Electrical  irritation  of  the  prae-frontal 
region  of  the  cortex  in  the  monkey  causes  no  motor  reaction  (Ferrier). 

Experiments  by  Extirpation. — Complete  destruction  of  the  pree-froutal 
lobes  in  the  monkey  causes  no  paralysis  of  motion  and  no  sensory  dis- 
turbance, but  the  character  of  the  animal  suffers  great  deterioration  sub- 
sequently to  the  operation.     "  Kemoval  or  destruction  by  the  cautery  of 
the  antero-frontal  lobes,"  says  Dr.  Ferrier,  "  is  not  followed  by  any  definite 
physiological  results.     The  animals  retain  their  appetites  and  instincts, 
and  are  capable  of  exhibiting  emotional  feeling.     The  sensory  faculties — 
sight,  hearing,  touch,  taste,  and  smell — remain  unimpaired.     The  powers 
of  voluntary  motion  are  retained  in  their  integrity,  and  there  is  little  to 
indicate  the  presence  of  such  an  extensive  lesion,  or  a  removal  of  so  large 
a  part  of  the  brain.     And  yet,  notwithstanding  this  apparent  absence  of 
physiological  symptoms,  I  could  perceive  a  very  decided  alteration  in  the 
animal's  character  and  behaviour,  though  it  is  difficult  to  state  in  precise 
terms  the  nature  of  the  change.     The  animals  operated  on  were  selected 
on  account  of  their  intelligent  character.      After  the  operation,  though 
they  might  seem  ■  to  one  who  had  not  compared  their  present  with  the 
past  fairly  up  to  the  average  of  monkey  intelligence,  they  had  undergone 
a  considerable  psychological  alteration.      Instead   of,  as  before,   being 
actively  interested  in  their  surroundings,  and  curiously  prying  into  all 
that  came  within  the  field  of  their  observation,  they  remained  apathetic 
or  dull,  or  dozed  off  to  sleep,  responding  only  to  the  sensations  or  impres- 
sions  of  the  moment,  or  varying  their  listlessness  with    restless    and 
purposeless  wanderings  to   and   fro.     While   not   actually  deprived   of 
GG 


498       ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION, 

intelligence,  they  had  lost  to  all  appearance  the  faculty  of  attentive  and 
intelligent  obeservation."  The  conclusions  which  Dr.  Ferrier  has  drawn 
from  his  experiments  on  animals  are  fully  borne  out,  as  we  shall  subse- 
quently see,  by  the  results  of  diseases  and  injuries  of  the  pree-frontal  lobes 
in  man.  The  whole  evidence  shows  that,  although  destruction  of  these 
lobes  is  not  followed  by  decided  sensory  or  motor  disturbances,  yet  that 
the  later  evolved  (representative  and  re-representative)  cognitions  and 
emotions  are  seriously  impaired. 

§  688.  Localisation  of  the  Mechanisms  which  regulate  the  Fundamental  and 
Accessory  Actions. 
We  have  already  seen  that  the  fundamental  portions  of  the  convolutions 
of  the  motor  area  of  the  brain  are  found  near  the  great  longitudinal  fissure, 
while  the  accessory  portions  of  these  convolutions  are  found  in  the  convo- 
lutions of  the  operculum ;  and  it  may  therefore  be  expected  that  the  funda- 
mental motor  actions  will  be  regulated  from  the  former,  and  the  accessory 
functions  from  the  latter.  Several  lines  of  evidence  converge  in  support 
of  this  view.  The  large  giant-cells  are  found  in  the  convolutions  near  the 
great  longitudinal  fissure,  while  these  cells  diminish  in  size  as  we  descend 
towards  the  convolutions  of  the  operculum.  But  we  have  already  seen  that 
the  size  of  the  motor  ganglion  cells  of  the  anterior  grey  horns  of  the  cord 
is  determined  by  the  size  of  the  muscles  whose  movements  they  regulate 
more  than  by  any  other  circumstance,  and  it  is  very  likely  that  a  similar 
relation  exists  between  the  giant-cells  of  the  cortex  and  the  muscles  with 
which  they  are  connected.  But  the  fundamental  actions  are,  as  a  rule, 
produced  by  the  contractions  of  large  muscles,  such  as  those  of  the  trunk 
and  lower  extremities,  and  consequently  we  may  expect  that  they  will  be 
regulated  by  means  of  the  large  cells  of  the  central  convolutions  near  the 
great  longitudinal  fissure ;  while,  on  the  other  hand,  the  accessory  actions 
are  produced  by  small  muscles,  such  as  those  of  the  hand,  larynx,  and 
face,  and  we  may  expect  that  they  will  be  regulated  through  the  smaller 
cells  of  the  convolutions  of  the  operculum.  Again,  the  fibres  of  the 
pyramidal  tract,  which  are  meduUated  in  a  nine  months  embryo — 
the  fundamental  fibres  —  are  connected  with  the  central  convolution 
near  the  great  longitudinal  fissure ;  while  the  non-medullated  fibres — 
the  accessory  fibres  of  the  tract — are  connected  with  the  convolutions 
of  the  operculum.  The  fibres  which  connect  the  posterior  portion  of  the 
third  frontal  convolution  with  the  internal  capsule  and  cruata  are  not  me- 
duUated before  fourteen  weeks  after  birtn  (Flechsig).  We  have  already 
seen  that  a  large  proportion  of  the  accessory  fibres  of  the  pyramidal 
tract  terminate  in  the  medulla  oblongata,  and  in  all  probability  the 
majority  of  them  are  concerned  in  regulating  the  special  movements  of 
articulation  and  facial  expression.  A  glance  at  Dr.  Ferrier's  diagrams 
{Figs.  232  and  233)  of  the  motor  centres  of  the  human  brain  shows  that 
the  movements  of  the  trunk  and  lower  extremities  are  regulated  from  the 
central  convolutions  near  the  great  longitudinal  fissure  ;  that  those  of  the 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.       499 

arma  are  regulated  from  the  middle  of  the  ascending  frontal  and  parietal 
convolutions ;  and  that  those  of  the  face,  tongue,  and  hand  are  regu- 
lated from  the  convolutions  of  the  operculum.  The  facts  of  development 
and  of  experimental  physiology,  therefore,  concur  to  shovf  that  the  funda- 
mental actions  are  regulated  from  the  central  convolutions  near  the  great 
longitudinal  fissure,  and  the  accessory  functions  from  the  convolutions  of 
the  operculum.  It  must  also  be  remembered  that  the  grey  matter  at  the 
bottom  of  the  fissures  is  developed  subsequently  to  that  of  the  summits,  and 
consequently  the  former  represents  an  organisation  which  has  been  super- 
added to  the  latter  in  the  course  of  evolution.  But  the  portion  of  the  cortex 
of  the  Island  of  Reil  which  adjoins  the  convolutions  of  the  operculum  is  the 
great  area  in  which  new  structure  is  superadded  to  the  motor  region  of  the 
cortex.  As  the  grey  matter  in  the  neighbourhood  of  the  anterior  perforated 
space  increases  in  superficial  extent,  the  external  aspect  of  the  cortex  of 
the  central  lobe  is  thrust  upwards  and  outwards  so  as  to  develop  the 
convolutions  of  the  operculum  ;  and  each  addition  of  grey  matter  to  the 
latter  convolutions  represents  an  additional  complexity  in  the  pre-existing 
structure  corresponding  to  an  additional  complexity  of  previous  muscular 
adjustments.  Each  increment  which  is  added  to  the  inferior  extremities 
of  the  central  convolutions  by  the  upward  growth  of  the  cortex  of  the 
Island  of  Reil  increases  the  length  of  the  former ;  but  as  their  upper  ex- 
tremities are  prevented  from  moving  freely  upwards  by  the  skull,  their 
lower  extremities  are  thrown  into  a  fold,  and  consequently  the  depth  of 
the  sulcus  which  separates  the  Island  of  Reil  from  the  convolutions  of  the 
operculum  may  be  accepted  as  an  indication  of  the  degree  of  development 
of  the  accessory  portion  of  the  motor  area  of  the  cortex. 

§  689.  Localisation  of  the  Cortical  Centres  ofGeTural  and  Special  Sensations. 
We  have  seen  that  in  the  spinal  cord  the  conducting  paths  of  the 
common  sensations  passed  directly  into  the  posterior  grey  horn,  through 
the  middle  of  the  fan  formed  by  the  fibres  of  the  posterior  roots  on  their 
entry  into  the  cord  ;  while,  on  the  other  hand,  the  conducting  paths  of 
the  special  cutaneous  sensations  are  thrust  inwards  and  outwards,  so 
as  to  occupy  positions  outside  the  margins  of  the  posterior  horns.  A 
somewhat  similar  process  appears  to  take  place  during  the  development 
of  the  cortex  in  relation  to  the  common  and  special  cutaneous  sensations 
and  the  special  senses.  According  to  the  latest  experiments  of  Ferrier 
and  Munk  the  centre  of  vision — the  most  special  of  all  the  senses — is 
situated  on  the  outer  convex  surface  of  the  occipital  lobe  in  the  area  of 
the  terminal  distribution  of  the  posterior  cerebral  artery,  while  the  centre 
of  tactile  sensation  is  situated  in  the  hippocampal  region,  close  to  the  root 
of  the  same  artery.  It  is  probable  that  the  sensation  of  pain  is  too  much 
diffused  in  the  cortex  to  admit  of  any  definite  localisation.  Both  the 
auditory  centre — the  superior  temporo-sphenoidal  convolution — and  the 
olfactory  centre — the  subiculum  cornu  Ammonis — although  situated 
nearer  the  root  of  the  artery  than  the  visual  centre,  yet  occupy  positions 


500       ANATOMICAL  AND   PHYSIOLOGICAL  INTEODUCTION. 

near  the  terminal  distribution  of  some  of  the  branches  of  the  posterior 
cerebral  artery,  and  certainly  further  removed  from  its  root  than  the 
centre  of  tactile  sensation. 

§  690.  Localisation  of  Function  in  the  Proe-frontal  Area  of  the  Cortex. 

If  the  higher  mental  operations  be  carried  on  in  the  anterior  area  of 
the  cortex,  this  region  must  contain  the  plexuses  of  cells  and  fibres,  which, 
when  excited,  become  the  correlatives  of  the  representative  and  re- 
representative  cognitions  and  feelings.  No  progress  has  been  made 
In  localising  the  functions  of  this  area  of  the  cortex.  It  is,  however, 
probable,  that  the  later-acquired  emotions  and  cognitions  will  be  repre- 
sented in  the  cortex  by  the  grey  matter  in  the  bottom  of  the  fissures,  and 
by  the  grey  matter  of  the  convolutions  of  the  orbital  surface  which 
adjoins  the  anterior  perforated  space  and  which  are  situated  close  to 
the  root  of  the  anterior  cerebral  artery.  Pathological  observation 
bears  out  the  idea  that  disease  of  the  cortex  of  the  orbital  surface 
produces  much  less  mental  disturbance  than  disease  of  the  superior 
convex  surface  of  the  pree-frontal  area.  And  this  is  only  what  might  be 
expected  if  the  former  is  developed  at  a  later  period  than  the  latter.  The 
convolutions  of  the  orbital  surface  would  then  represent  the  later-acquired 
cognitions  and  emotions,  and  abolition  of  them  would  cause  less  mental 
disturbance  than  abolition  of  those  which  are  earlier  acquired  but  more 
fundamental.  A  man,  for  instance,  may  live  what  is  regarded  as  a 
respectable  life  when  he  is  destitute  of  all  reverence,  and  is  wholly  in- 
capable of  doing  an  unselfish  action,  while  the  only  self-restraint  he 
places  over  his  appetites  and  passions  is  that  which  the  most  calculating 
selfishness  suggests.  Yet  reverential  feeling,  unselfishness  in  action,  and 
self-restraint  are  the  latest  acquisitions  in  the  development  of  the  human 
mind.  If,  however,  a  man,  instead  of  being  lacking  in  reverential  feeling, 
becomes  openly  profane,  and  instead  of  not  being  unselfish  he  commits 
deeds  of  violence  in  order  to  deprive  others  of  their  rightful  property,  and  if 
instead  of  curbing  his  passions  even  by  a  calculating  selfishness  he  gratifies 
them  without  shame  and  regardless  of  consequences,  it  is  evident  that  a 
lower  stratum  of  mental  degradation  has  been  reached,  and  the  portion  of 
the  cortex  now  diseased  is  a  more  fundamental  one,  which  must  have  been 
developed  at  an  earlier  period  than  that  which  was  diseased  in  the  first 
instance. 


501 


CHAPTER    II. 


MOEBID  ANATOMY  AND  CLASSIFICATION  OF  THE  DISEASES 
OF  THE  ENCEPHALON. 


(I.)— MORBID  ANATOMY  OF  THE   ENCEPHALON. 

The  operation  of  the  law  of  evolution  having  been  already 
traced  in  the  construction  of  the  brain,  we  must  now  endea- 
vour to  trace  the  action  of  the  law  of  dissolution  in  the 
breaking  down  of  structure  the  result  of  disease. 

§  691.  Histological  Morbid  Changes. — The  histological 
changes  which  occur  in  the  tissues  of  the  brain  during  diseased 
processes  are  essentially  the  same  as  those  which  have  already 
been  described  in  the  case  of  the  spinal  cord  (§  887),  and  it  is, 
therefore,  unnecessary  to  repeat  the  description. 

§  692,  Morbid  Alterations  of  the  Circulation  within  the 
Cranium. — It  was  first  pointed  out  by  the  second  Monroe  that 
the  circulation  within  the  cranium  differs  from  that  of  other 
parts  of  the  body.  The  cranium  forms  a  bony  case,  capable  of 
resisting  the  atmospheric  pressure,  and  no  substance  can  be 
dislodged  from  it  without  some  equivalent  taking  its  place; 
while,  on  the  other  hand,  no  substance  can  be  added  to  the  con- 
tents of  the  cranium  without  dislodging  an  equivalent  bulk  of 
some  other  substance.  This  opinion  was  experimentally  tested 
by  Kellie,  and  defended  by  Abercrombie,  Reid,  and  Watson. 
Dr.  Burrows  endeavoured  to  combat  this  opinion,  but  he  only 
showed,  what  was  never  denied,  that  the  quantity  of  blood  in 
the  brain  could  be  increased  or  diminished  by  various  circum- 
stances. The  doctrine  of  Monroe  simply  asserts  that  if  the 
quantity  of  blood  in  the  cavity  of  the  cranium  be  increased, 


502  MORBID  ANATOMY  AND   CLASSIFICATION 

some  other  fluid  must  be  dislodged;  while  if  the  quantity  of 
blood  be  diminished,  some  other  fluid  must  fill  up  the  vacant 
space.  The  quantity  of  blood  in  the  brain  can  undoubtedly 
be  increased  or  diminished,  but  this  can  only  take  place  by  a 
corresponding  diminution  or  increase  in  the  quantity  of  the 
cerebro-spinal  fluid  and  of  the  fluid  contained  in  the  peri- 
vascular lymph  spaces.  When,  however,  the  intracranial  pres- 
sure is  rendered  still  greater,  as  by  extravasation  of  blood 
from  rupture  of  a  blood-vessel,  room  is  made  for  the  sub- 
stance superadded  to  the  contents  of  the  cranium  by  a  certain 
quantity  of  blood  being  squeezed  out  of  the  intracranial 
arteries,  veins,  and  sinuses,  in  addition  to  the  displacement  of 
the  cerebro-spinal  fluid.  The  circulation  within  the  cranium  is 
liable  to  be  disordered  by  occlusion  or  rupture  of  one  or  more 
of  the  intracephalic  vessels,  but  the  reader  is  referred  to  the 
sections  on  embolism,  thrombosis,  and  cerebral  haemorrhage  for 
detailed  descriptions  of  these  processes. 

Tumours. — The  growth  of  intracranial  tumours  of  all  kinds 
must  necessarily  be  attended  by  great  disturbance  of  the  cere- 
bral circulation.  In  order  to  make  room  for  the  increasing  bulk 
of  the  tumours  the  cerebro-spinal  fluid,  as  well  as  the  fluid  of 
the  perivascular  lymph  spaces,  is  first  squeezed  out,  the  blood 
is  then  compressed  from  the  intracranial  blood-vessels,  so  that 
the  whole  brain  is  rendered  anaemic. 

§  693.  Secondary  Degenerations. — Long-standing  hsemor- 
rhagic  and  other  diseased  foci  give  rise  to  various  secondary 
changes  not  only  in  the  surrounding  tissues,  but  also  in  distant 
parts.  These  changes  are  of  two  kinds :  firstly,  those  which 
involve  the  entire  mass  of  the  brain ;  and  secondly,  those 
limited  to  certain  tracts  of  conducting  fibres,  which  are  inter- 
rupted in  their  course  by  the  hsemorrhage. 

(1)  General  Atrophy.  —With  regard  to  the  former  of  these 
kinds,  it  is  found  that  the  brain  frequently  undergoes,  even 
after  an  insignificant  hsemorrhage,  a  slow  and  general  atrophy 
which  occasionally  aflects  both  hemispheres.  This  condition  is 
especially  common  after  extravasations  into  the  cortex.  A  per- 
sistent alteration  of  one  hemisphere  of  the  brain  may  after 
a  time  induce  atrophy  of  the  opposite  hemisphere  of  the 
cerebellum. 


OF   THE   DISEASES  OF   THE  ENCEPHALON. 


503 


(2)  Systemic  Degeneration. — As  has  been  frequently  stated, 
whenever  the  fibres  of  the  pyramidal  tract  are  injured  in  any 
part  of  their  course  from  their  origin  in  the  cortex  of  the  brain 
down  to  their  termination  in  the  spinal  cord,  the  portions  below 
the  seat  of  injury  undergo  descending  degeneration. 

A  focal  lesion,  limited  to  the  middle  third  of  the  iwsterior  segment  of 
the  internal  capsule  {Fig.  237,  F),  is  followed  by  descending  degeneration 
of  the  fibres  of  the  middle  third  of  the  crasta  {Fig.  238,  L),  and  of  a 
portion  of  the  longitudinal  fibres  of  the  pons  and  anterior  pyramid  of  the 
medulla. 

In  the  lower  end  of  the  medulla  the  greater  part  of  the  degenerated  fibres 
cross  over  to  the  lateral  column  of  the  opposite  side  of  the  cord  {Fig.  239, 
A),  while  some  of  them  pass  down  the  column  of  Tiirck  of  the  same  side 
{Fig.  239,  B).  The  course  pursued  by  the  secondary  degeneration  in  the  case 

Fig.  237. 


Fig.  237  (Charcot).  Horizontal  Section  of  the  Right  Hemisphere  parallel  with  the 
Fissure  of  Sylvius. — Nc,  Caudate  nucleus ;  Sa,  Anterior  segment  of  the  in- 
ternal capsule ;  Nl,  Lenticular  nucleus ;  G,  Knee  of  the  internal  capsule ;  Sp, 
Posterior  segment  of  the  internal  capsule ;  Co,  Optic  thalamus ;  F,  A  focal 
lesion  in  the  middle  third  of  the  posterior  part  of  the  internal  capsule. 


504* 


MORBID  ANATOMY  AND   CLASSIFICATION 


Fig.  238. 


F  L  D 


Fig.  238  (Charcot).  Hoi'izontal  Section  of  the  Crura  Cerebri  in  a  case  of  Secondary 
Degeneration. — T,  Tegmentum;  F,  Crusta  of  the  healthy  side;  L,  Locus 
niger;  D,  The  degenerated  fibres,  occupying  about  the  middle  third  of  the 
crusta ;  P,  The  fibres  which  undergo  secondary  degeneration  only  when  the 
fibres  of  the  anterior  segment  and  the  knee  of  the  internal  capsule  are  diseased. 


Fig.  239. 


Fig.  239  (Charcot).  Transverse  Section  of  the  Cervical  Region  of  the  Sjyinal  Cord, 
from  a  case  of  lesion  of  the  motor  area  of  the  cortex  of  the  opposite  hemisphere. — 
A,  Degeneration  of  the  pyramidal  tract ;  B,  Degeneration  of  the  direct  fibres ; 
C,  Direct  cerebellar  tract ;  D,  Intermediate  region  between  the  posterior  grey 
horn  and  the  pyramidal  tract,  the  fibres  of  which  do  not  undergo  descending 
degeneration. 


OF   THE   DISEASES   OF  THE  ENCEPHAEON. 


505 


just  described  corresponds  to  that  of  the  fundamental  fibres  of  the  pyra- 
midal tract  during  their  development  {Figs.  223  and  224).  A  case  has 
been  described  by  Brissaud  in  which,  along  with  extensive  recent  softening 
of  one  hemisphere,  an  old  focus  of  softening  was  observed  limited  exactly 
to  the  knee  of  the  internal  capsule  {Fig.  240,  D).    A  streak  of  degeneration 

Fig.  240. 


Fig.  240  (Brissaud).  Recent  Softening  of  the  Frontal  Lohe,  the  Island  of  Eeil,  and 
Middle  Third  of  the  Lenticulai' Nucleus. —T),  Old  iocus  of  softening  occupying 
the  knee  of  the  internal  capsule;  A,  Caiidate  nucleus;  B,  Optic  thalamus ; 
C,  Anterior,  and  E,  Posterior  division  of  the  internal  capsule. 


was  observed  lying  between  the  internal  and  middle  thirds  of  the  crusta, 
being  the  anterior  portion  of  the  area  which  has  already  been  described  as 
the  mixed  area  of  medullated  and  non-meduUated  fibres  in  a  nine  months 
embryo  {Fig.  223).  According  to  Brissaud  degeneration  occurs  in  the  knee 
of  the  internal  capsule  in  cases  of  long-standing  aphasia. 

Another  important  case  has  been  observed  by  Brissaud  in  which  an 
old  focus  of  softening  was  found  in  the  anterior  half  of  the  lenticular 
nucleus,  destroying  also  the  anterior  segment  of  the  internal  capsule 
{Fig.  241,  F).  A  streak  of  degeneration  was  observed  in  the  internal 
third  of  the  crusta  {Fig.  241,  P),  but  all  the  fibres  of  this  area  were  not 
implicated  in  the  degeneration,  a  small  bundle  of  the  innermost  fibres 
remaining  normal.  The  degenerated  fibres  in  this  case  corresponded  very 
nearly  to  those  which  we  have  described  as  the  accessory  fibres  of  the  tract. 
Degeneration  of  the  internal  tract  of  the  crusta,  according  to  Brissaud, 
appears  to  be  always  connected  with  intellectual  disorders. 


506 


:^rOEBED  ANATOIirT  AND   CLASSIFICATION 


The  iollowing  bundles  of  fibres  may,  therefore,  be  distingxiished.  in  the 
internal  capsule  (Brissaud) : — 

(1)  A.  posterior  or  sensory  fascicuhis  (occupying  the  external  third  of  the 
crusta),  which  is  never  the  seat  of  secondary  degeneration. 

(2)  A  middle  fasciculus  (occupying  the  middle  third  of  the  crusta), 
which  is  the  usual  seat  of  secondary  degeneration. 

(3)  A  geniculate  fasciculus  (occupying  the  point  of  union  of  the  middle 
and  internal  thirds  of  the  crusta),  which  has  erroneously  been  regarded  as 
incapable  of  degeneration.  This  fasciculus  contaias  fibres  which  ax'e  dis- 
tributed to  the  bulbar  centres,  and  are.  concerned  in  the  production  of  the 
voluntary  movements  of  the  face  and  tongue. 

(4)  An  anterior  fasciculus  (occupying  the  internal  third  of  the  crusta), 
degeneration  of  which  appears  only  to  be  associated  with  intellectual 
disorders. 

Fig.  241. 


Fig.  241  (Brissaud). — A,  Caudate  nucleus ;  B,  Optic  thalamus  ,*  C,  Posterior  and 

healthy  part  of  the  lenticular  nucleus ;  D,  Posterior  segment  of  the  internal 
capsule ;  E,  Lesion  of  the  anterior  segment  of  the  capsule ;  F,  Cyst  pre- 
senting the  form  of  the  lenticular  nucleus;  P,  Degeneration  of  the  internal 
fibres  of  the  crusta. 


OF   THE   DISEASES   OF   THE    ENCEPHALOX.  507 

§  694.  Congenital  Malformations  oftlie  Shull  and  Brain. 

(1)  Anencephalia. — In  this  condition  the  upper  portion  of  the  sloill  and 
brain  is  entirely  absent.  This  condition  is  sometimes  associated  vrith 
amyelia,  a  condition  in  which  the  vertebral  column  remains  xmclosed,  and 
the  spinal  cord  is  wanting  (Forster). 

(2)  Hemicrania. — The  anterior  portion  of  the  skull  is  absent  and  the 
brain  deficient. 

(3)  ffemicepho.Ua. — The  lateral  half  of  the  brain  and  skull  is  deficient. 

(4)  Notencephalus. — The  upper  part  of  the  skull  is  deficient,  and  the 
vertebral  column  is  not  entirely  closed  in,  while  the  brain  develops  in  the 
vertebral  canal  instead  of  the  skulL 

(5)  Hydrencephalocele. — In  this  condition  the  bones  of  the  skull  are 
deficient,  an  opening  being  left,  generally  at  one  of  the  fontaneUes,  through 
which  a  soft,  fluctuating  ttunoiu"  projects.  The  tumour  contains  fluid,  and 
can  generally  be  emptied  by  steady  pressure.  The  walls  of  the  tumour 
consist  of  the  soft  coverings  of  the  skull,  and  the  distended  membranes  of 
the  brain.  The  tumour  communicates  with  the  general  ventricular  cavity 
of  the  brain. 

(6)  EncephaloceU. — The  bones  of  the  skull  are  again  deficient  at  some 
part  in  this  condition,  but  through  the  opening  formed  a  portion  of  the 
brain  itself  projects,  forming  a  broad,  flat,  solid  tumour.  The  tumour 
&«quently  occupies  the  forehead,  orbit,  or  side  of  the  nose. 

§  695.  The  Low  of  Dissolution. — Although  the  law  of  disso- 
lution is  probably  destined  at  some  future  time  to  throw  more 
light  on  the  morbid  anatomy  of  the  brain  than  on  that  of  any 
other  organ  of  the  body,  yet  it  must  be  admitted  that  up  to 
the  present  very  little  progress  has  been  made  in  this  direction. 
The  law  has  been  applied  by  Dr.  Hughlings-Jackson  with 
much  ingenuity  and  success  to  the  interpretation  of  disordered 
cerebral  functions,  but  it  has  yet  to  be  applied  to  the  eluci- 
dation of  morbid  cerebral  structures.  The  histological  elements 
of  the  brain  doubtless  conform  to  this  law  in  their  degene- 
rations in  a  manner  similar  to  that  already  described  with 
regard  to  the  histological  elements  of  the  spinal  cord.  And 
even  when  the  disease  is  diffused  in  the  neuroglia  the  small 
cells  and  thin  fibres  of  the  accessory  portion  of  the  brain 
must  suffCT  injury  more  readily  than  the  large  cells  and  thick 
fibres  of  the  fundamental  portion.  This  a  priori  necessity  has 
not,  however,  been  verified  as  yet  by  a  posteriori  observations. 
Even  in  such  a  coarse  lesion  as  that  caused  by  occlusion  of  one 
of  the  cerebral  arteries — sav  the  inferior  frontal  branch  of  the 


508  MORBID  ANATOMY  AND   CLASSIFICATION 

left  Sylvian  artery — the  operation  of  this  Jaw  may  probably  be 
traced.  If,  as  we  have  already  endeavoured  to  prove,  the  later- 
formed  cells  and  fibres  of  Broca's  convolution  lie  near  the  root 
of  this  artery,  while  the  earlier-formed  cells  and  fibres  are 
thrust  upwards  and  forwards  towards  the  terminal  twigs  of  the 
vessel,  it  is  manifest  that  the  earlier  is  in  a  much  more  favour- 
able position  than  the  later  developed  portion  to  obtain  nourish- 
ment from  the  neighbouring  vascular  territories.  But  this  con- 
clusion, although  there  is  much  probability  in  its  favour,  has 
not  yet  been  confirmed  by  careful  dissection.  These  brief 
and  imperfect  remarks  are  all  that  we  feel  justified  in  making, 
in  the  present  state  of  our  knowledge,  with  regard  to  the 
applicability  of  the  law  of  dissolution  to  the  structural  altera- 
tions produced  by  disease  in  the  brain. 

(II.) -CLASSIFICATION   OF  THE   DISEASES   OF  THE 
ENCEPHALON. 

It  is  impossible  to  give  a  full  and  scientific  classification 
of  the  diseases  of  the  encephalon,  inasmuch  as  a  large  propor- 
tion of  them  are  beyond  the  scope  of  this  work.  It  is  not  our 
intention  to  enter  upon  the  discussion  of  the  wide  class  of 
diseases  of  the  brain  comprised  under  the  general  term  insanity, 
and  yet  no  classification  of  the  diseases  of  the  encephalon  can 
be  considered  satisfactory  which  does  not  comprise  them.  In 
endeavouring  to  classify  the  diseases  which  remain,  we  shall 
proceed  on  the  principle  of  considering  first  those  which  give 
rise  to  the  fewest,  and  leaving  to  the  last  those  that  occasion 
the  most  numerous  and  complicated  symptoms.  Now  as  disease 
of  the  membranes  can  hardly  ever  exist  without  producing 
secondary  disease  over  a  large  area  of  the  surface  of  the  brain, 
the  symptoms  characterising  the  former  may  be  expected  to  be 
on  the  whole  more  complicated  than  those  of  the  latter,  and 
consequently  the  diseases  of  the  encephalon  will  be  considered 
prior  to  those  of  the  membranes.  Of  the  diseases  of  the 
encephalon,  the  lesions  which  give  rise  to  the  least  complicated 
symptoms  are  the  focal,  and  those  which  give  rise  to  the  most 
complicated  symptoms  are  the  diffused  lesions.  It  is  known 
that  a  focal  lesion,  as  a  tumour,  may  by  increasing  the  intra- 
cranial pressure  and  in  other  ways  give  rise  to  diffused  effects, 


OF  THE  DISEASES  OF  THE  ENCEPHALON.  509 

and  that  a  diffused  disease  like  encephalitis  may  by  terminating 
in  abscess  occasion  local  symptoms.  The  division  into  focal  and 
diffused  lesions  is,  therefore,  not  a  scientific  but  a  practical  dis- 
tinction, and  must  be  judged  entirely  from  a  practical  stand- 
point. The  symptoms  caused  by  focal  diseases  depend  partly 
upon  the  nature  and  partly  upon  the  locality  of  the  lesion. 
Cerebral  haemorrhage,  for  instance,  occasions  a  grouping  of 
symptoms  which  enables  the  affection  to  be  readily  distinguished 
from  the  symptoms  produced  by  the  slow  growth  of  an  intra- 
cranial tumour ;  yet  the  symptoms  caused  by  destruction  of  a 
certain  portion  of  the  internal  capsule,  for  instance,  is  the  same 
whether  the  injury  be  caused  by  haemorrhage  or  by  the  growth 
of  a  tumour.  The  focal  diseases,  therefore,  admit  of  considera- 
tion under  two  aspects:  (I.)  according  to  the  symptoms  common 
to  the  pathological  state  in  general;  and  (II.),  according  to  the 
special  functions  of  the  region  affected.  With  these  few 
remarks  the  following  classification  may  be  allowed  to  explain 
itself : — 

A.  Diseases  of  the  Encephalon. 
I.  Focal  diseases. 

(i.)  General  consideration  of  focal  diseases,  according 
to  the  nature  of  the  lesion. 

1.  Occlusion  of  intracranial  vessels. 

2.  Intracranial  haemorrhage. 

3.  Intracranial  tumours. 

(ii.)  Special  consideration   of  focal  diseases,  according 
to  the  localisation  of  the  lesion. 

1.  Affections  of  peduncular  fibres  and  internal  capsule. 

a.  Affections  of  the  pyramidal  tract. 

(i.)  Hemiplegia, 
(ii.)  Hemispasm. 

b.  Affections  of  the  sensory  peduncular  fibres  and  optic 

radiations  of  Gratiolet. 
(i.)  Hemiansesthesia. 

2.  Lesions  of  the  cortex  of  the  brain  and  of  the  subjacent 

portion  of  the  centrum  ovale. 
a.  Lesions  in  the  area  of  the  middle  cerebral  artery, 
(i.)  Unilateral  convulsions,  and  mouosj)asms. 
(ii.)  Monoplegise. 
(iii.)  Cortical  affections  of  speech. 


510       CLASSIFICATION   OF   DISEASES  OF   THE   ENCEPHALON. 

b.  Lesions  in  the  area  of  the  posterior  cerebral  artery. 

c.  Lesions  in  the  area  of  the  anterior  cerebral  artery. 

3.  Lesions  in  the  basal  ganglia,  external  capsule,  claustnim, 

and  base  of  the  brain. 

4.  Lesions  localised  in  the  structures  situated  below  the 

tentorium. 
a.  Lesions  in  the  pons  and  peduncles  of  the  cerebrum. 
h.   Lesions  in  the  peduncles  of  the  cerebellum. 
c.    Lesions  in  the  cerebellum. 

II.  Diffused  diseases  of  the  encephalon. 

(l.)  Aneemia  and  hypersemia  of  the  brain, 
(ii.)  Atrophy  and  hypertrophy  of  the  brain. 
(ill.)  Shock,  and  concussion  of  the  brain, 
(iv.)  Encephalitis. 

1.  General  encephahtis. 

2.  Partial  encephahtis. 

a.  Acute  encephalitis,  complicating  affections  of  the 
petrous  portion  of  the  temporal  and  other  bones 
of  the  skull. 

h.  Acute  pysemic  encephalitis. 

c.  Encephalitis  secondary  to  other  cerebral  lesions. 

d.  Chronic  abscess  of  the  brain. 

B.  Diseases  of  the  Membranes  of  the  Brain. 

I.  Diseases  of  the  dara  mater. 

(i.)  External  pachymeningitis, 
(il.)  Internal  pachymeningitis. 

II.  Diseases  of  the  pia  mater. 

Acute  inflammation  of  the  pia  mater. 

1.  Leptomeningitis  Infantum. 

2.  Tubercular  meningitis. 

3.  Meningitis  of  the  base  of  the  brain. 

4.  Meningitis  of  the  convexity  of  the  brain. 

5.  Metastatic  meningitis. 

6.  Traumatic  meningitis. 


511 


CHAPTEE  III. 


(I.)    GENERAL  CONSIDERATION    OF   FOCAL  DISEASES, 
ACCORDING  TO  THE  NATURE  OF  THE  LESION. 


1.  OCCLUSION  OF  THE  INTRACRANIAL  VESSELS. 

The  arteries,  veins,  sinuses,  and  capillaries  of  the  brain  are 
liable  to  become  occluded,  a  circumstance  which  gives  rise  to 
various  pathological  changes.  The  occluding  body  may  be 
formed  on  the  spot,  constituting  thrombosis ;  or  may  be  carried 
from  distant  parts,  constituting  embolism. 

(a)  Occlusion  of  the  Cerebral  Arteries. 

§  696.  Etiology. — Emboli  consist  of  fibrinous  masses  washed 
away  from  the  left  cavities  of  the  heart,  the  aortic  and  mitral 
valves,  the  arch  of  the  aorta,  and  occasionally  from  the  pulmonary 
veins.  In  cases  of  carcinoma  of  the  lungs,  a  cancerous  mass 
may  possibly  be  carried  from  the  pulmonary  veins  and  pass 
into  the  cerebral  vessels. 

Arterial  thrombosis  is  determined  partly  by  general  causes 
tending  to  diminish  the  force  of  the  heart's  action  and  to  alter 
the  quality  of  the  blood,  and  in  part  by  local  degenerations  of 
the  coats  of  the  vessels  themselves.  During  convalescence  from 
acute  diseases  and  other  exhausting  processes,  the  heart  is  weak, 
and  the  blood  becomes  so  altered  in  quality  that  it  is  specially 
prone  to  coagulate.  This  process  is,  of  course,  much  favoured 
if  the  heart  have  undergone  dilatation  without  proportionate 
hypertrophy.  The  local  causes  of  thrombosis  are  alterations  of 
the  walls  of  the  arteries,  whereby  their  lining  membrane  is 
roughened  and  their  calibre  is  narrowed.  The  coagulation  of 
fibrine  is  favoured  by  changes  in  the  walls  and  internal  surface 
of  the  vessel,  such  as  those  due  to  atheromatous  and  calcareous 


512  FOCAL   DISEASES,   ACCORDING  TO 

degenerations.  Thrombosis  is  particularly  liable  to  occur  when 
general  causes  and  local  degeneration  act  together. 

Thrombosis  may  take  place  in  any  of  the  arteries  at  the  base 
of  the  brain,  or  in  several  of  them  at  the  same  time.  A  thrombus 
not  unfrequently  forms  in  one  of  the  internal  carotid  arteries, 
and  the  clot  then  often  extends  into  the  middle  and  anterior 
cerebral  arteries  of  the  same  side,  and  sometimes  even  into  the 
posterior  communicating  and  the  posterior  cerebral  artery. 

Of  the  predisposing  causes  of  cerebral  thrombosis  age  is 
probably  the  most  important.  Thrombosis  occurs  more  fre- 
quently in  advanced  age,  owing  to  the  degenerative  changes 
in  the  vessels,  although  it  may  occur  at  all  ages.  Embolism, 
on  the  other  hand,  is  met  with  in  relatively  young  persons, 
although  it  may  also  occur  in  persons  of  advanced  years. 

§  697.  Sympto'ms. — The  symptoms  which  characterise  the 
later  stages  of  thrombosis  and  embolism  are  the  same,  but  those 
of  the  early  period  differ  considerably. 

The  symptoms  of  embolism  are  very  sudden  in  their  onset, 
and  are  not  preceded  by  any  premonitory  signs.  The  patient  is 
suddenly  attacked  with  dizziness,  utters  an  involuntary  cry,  or 
complains  momentarily  of  headache,  and  then  almost  imme- 
diately loses  consciousness.  The  symptoms  occasioned  by 
embolism  of  a  cerebral  artery  are  in  their  general  characters 
and  mode  of  onset  almost  identical  with  those  of  cerebral 
bsemorrhage,  but  the  unconsciousness  caused  by  embolism  is, 
as  a  rule,  more  transient  than  that  produced  by  hgemorrhage. 

In  many  cases  there  is  no  coma,  but  only  some  dizziness  or 
slight  confusion  of  mind  for  a  minute  or  two,  along  with  the 
sudden  advent  of  paralysis.  The  attack  is  sometimes  ushered 
in  by  epileptiform  convulsions,  which  may  sometimes  be  general 
like  an  ordinary  epileptic  attack,  but  are  at  other  times  limited 
to  one -half  of  the  body,  to  one  extremity,  or  one-half  of  the  face. 
When  general  convulsions  are  present  they  occur  simul- 
taneously with  the  loss  of  consciousness,  and  are  followed  by 
paralysis  immediately,  while  unilateral  and  partial  convulsions 
may  recur  repeatedly  before  paralysis  is  fully  established.  In 
some  cases  the  attack  is  accompanied  by  vomiting,  and  Hammond 
reports  a  case  in  which  active  delirium,  and  another  in  which 


THE   NATURE   OF   THE   LESION.  513 

hallucinations  and  delusions  were  present  for  some  hours  after 
a  sudden  attack  of  hemiplegia.  The  presence  of  disease  of  the 
aortic  and  mitral  valves  in  Hammond's  cases  rendered  the 
diagnosis  of  embolism  very  probable. 

In  many  cases  sudden  speechlessness,  a  condition  which  will 
be  subsequently  described  as  aphasia,  constitutes  the  only 
symptom  of  the  affection,  and  in  these  cases  the  symptom  may 
disappear  in  a  few  days  when  collateral  circulation  is  estab- 
lished. As  a  rule,  however,  the  aphasia  is  associated  with 
right-sided  hemiplegia,  which  possesses  the  same  general 
characters  as  that  which  results  from  haemorrhage  into  the 
lenticular  nucleus  and  neighbouring  parts.  The  right  side  is 
more  frequently  affected  with  paralysis  than  the  left,  owing  to 
the  greater  liability  of  the  left  middle  cerebral  artery  to  be 
affected  by  embolism.  The  state  of  the  pupils  during  the  onset 
of  the  attack  has  been  variously  described,  and  it  probably 
varies  in  different  cases.  Erlenmeyer  states  that  the  pupils 
remain  sensitive,  being  neither  contracted  nor  dilated,  while 
Hammond  has  found  dilatation,  contraction,  or  irregularity. 

The  symptoms  of  thrombosis  are,  as  a  rule,  more  gradual  in 
their  development  than  those  of  embolus.  The  more  usual 
premonitory  symptoms  of  thrombosis  of  a  cerebral  vessel  con- 
sist of  headache,  which  may  be  diffused  through  the  entire 
head  or  referred  to  the  neighbourhood  of  the  morbid  process 
(Hammond),  dizziness,  and  a  sense  of  general  confusion.  The 
patient  may  complain  of  numbness,  coldness,  or  formication  in 
one  extremity  or  throughout  the  distribution  of  one  nerve 
or  in  the  entire  half  of  the  body.  At  times  there  may  be 
considerable  mental  disturbances,  and  failure  of  memory  is 
often  a  marked  symptom.  Motor  disturbances  are  usually  of 
the  nature  of  more  or  less  extensive  paresis,  but  occasionally 
the  loss  of  motor  power  is  preceded  by  slight  convulsive  move- 
ments. Paralysis  may  occasionally  supervene  suddenly,  but,  as 
a  rule,  its  development  is  slow  and  gradual,  its  progress  being 
marked  by  successive  remissions  and  exacerbations.  This  mode 
of  development  appears  to  be  due  to  the  fact  that  thrombosis 
has  a  tendency  to  extend  backwards  and  to  implicate  more  and 
more  of  the  arterial  branch,  in  whose  ultimate  twigs  the  process 
may  have  first  begun.  The  duration  of  the  prodromal  stage 
HH 


514  FOCAL   DISEASES,   ACCORDING  TO 

may  vary  from  a  few  hours  to  several  months,  and  occasionally 
apoplectic  symptoms  may  come  on  suddenly,  as  in  embolism. 
When  once  the  vessel  has  become  completely  occluded,  the 
further  progress  of  thrombosis  is  like  that  of  embolism  in  the 
same  situation. 

When  softening  occurs  the  temperature,  according  to  Bourn e- 
ville,  rises  on  the  second  or  third  day  after  the  attack,  and  in 
two  or  three  days  may  be  as  high  as  40°  C.  (104°  F.).  In  a  few 
days  longer  the  temperature  sinks  rapidly,  its  decline  being 
more  rapid  than  that  which  takes  place  after  the  period  of  re- 
action in  cases  of  haemorrhage.  When  once  softening  has 
become  thoroughly  established  the  symptoms  are  those  which 
result  from  localised  cerebral  disease  generally,  and  indeed  the 
symptoms  of  softening  and  of  haemorrhage  when  regarded  as 
localised  diseases  are  often  identical. 

Contractures  of  the  paralysed  limbs  are  not  so  common  in 
cases  of  occlusion  of  vessels  as  in  cases  of  haemorrhage,  but  they 
occur  sufficiently  often  to  make  their  presence  or  absence 
destitute  of  diagnostic  significance. 

The  sensory,  trophic,  and  vaso-motor  disturbances,  as  well 
as  the  affections  of  the  special  senses,  with  the  exception  of 
vision,  are  the  same  as  those  which  occur  in  connection  with 
cerebral  haemorrhages.  In  some  cases  of  embolism  the  ophthal- 
mic artery  has  become  occluded,  giving  rise  to  sudden  amaurosis. 
On  ophthalmoscopic  examination  the  arteries  of  the  retina  are 
seen  to  be  empty ;  they  appear  like  fine  threads,  but  still  re- 
tain their  red  colour.  The  veins  are  not  much  diminished  in 
size,  and  are  filled  with  dark  blood.  The  retina  presents  a 
greyish  or  white  opacity  which  is  most  marked  around  the 
macula  lutea,  but  the  fovea  centralis  remains  of  a  bright  red 
colour,  forming  a  marked  contrast  with  the  pallor  of  the  sur- 
rounding portion  of  the  retina. 

Various  disturbances  of  the  mental  faculties  may  result  from 
embolic  softening.  Probably  the  most  interesting  of  these  is 
aphasia,  which  results  from  embolism  of  the  middle  cerebral 
artery  generally  of  the  left  side,  but  this  condition  will  be  dis- 
cussed at  greater  length  in  a  future  chapter. 

In  some  cases  of  occlusion  of  cerebral  arteries  the  symptoms 
begin  to  improve  at  an  early  period,   and  the  patient  may 


THE   NATURE   OF   THE   LESION.  515 

ultimately  recover  completely.  In  these  cases  it  is  evident 
that  the  collateral  circulation  has  been  established  before 
softening  has  commenced.  In  other  cases  the  patient,  after 
partial  or  complete  recovery,  is  attacked  again  with  embolism, 
and  there  may  be  a  second  recovery.  In  some  cases  of  throm- 
bosis the  first  symptoms  may  be  of  moderate  severity,  and  may 
afterwards  become  by  sudden  accessions  more  and  more  severe. 

In  some  few  cases  death  may  follow  immediately,  but  as  a 
rule  it  is  not  so  sudden  as  in  haemorrhage. 

Diseases  of  the  mitral  or  aortic  valves,  aortic  aneurism, 
ulcerative  endocarditis,  and  inflammatory  or  syphilitic  affec- 
tions of  the  muscular  substance  of  the  heart  are  the  compli- 
cations usually  met  with.  In  cases  of  thrombosis  evidences  of 
degeneration  of  the  vascular  system  can  usually  be  detected  in 
the  radial  and  other  arteries.  Important  symptoms  may  arise 
from  embolism  in  the  spleen,  the  kidneys,  and  the  arteries  of 
the  extremities. 

§  698.  Diagnosis. — The  problem  of  diagnosis  is  to  distin- 
guish cerebral  embolism,  thrombosis,  and  haemorrhage  from 
one  another.  This  must  be  done,  not  so  much  by  means  of 
the  cerebral  as  of  the  associated  symptoms. 

When  sudden  hemiplegia  occurs  in  a  young  or  middle-aged 
person  who  is  suffering  from  valvular  disease  of  the  heart  or 
aneurism,  the  symptoms  are  in  all  probability  due  to  embolism. 
The  probability  of  embolism  of  a  cerebral  artery  is  rendered 
still  greater  if  there  be  a  history  of  previous  seizures  in  the 
brain  or  other  organs.  Kight-sided  hemiplegia,  with  aphasia, 
results  more  frequently  from  embolism  of  the  left  middle  cerebral 
artery  than  from  any  other  cause,  and  consequently  in  such 
cases  the  presumption  is  always  in  favour  of  occlusion  of  the 
vessel  rather  than  haemorrhage,  provided  there  be  the  necessary 
conditions  for  its  occurrence.  There  are  no  absolute  means  of 
distinguishing  between  haemorrhage  and  thrombosis,  and  it  is 
needless  to  discuss  the  various  diagnostic  signs  which  have  from 
time  to  time  been  proposed. 

§  699.  Morbid  Anatomy. — Embolism  affects  certain  vessels 
with  special  frequency.     The  mode  of  origin  of  the  left  carotid 


516  FOCAL   DISEASES,   ACCORDING  TO 

directly  from  the  arch  of  the  aorta,  and  the  angle  at  which  it 
leaves  the  arch,  very  much  favour  emboli  being  carried  into 
it.  These  emboli  usually  pass  the  circle  of  Willis  and  make 
their  way  into  the  left  middle  cerebral  artery,  which  is  the 
direct  continuation  of  the  internal  carotid,  and,  consequently, 
this  artery  is  more  frequently  occluded  by  an  embolus  than 
any  other  vessel  of  the  brain. 

Thrombosis  does  not  appear  to  have  a  special  preference  for 
any  one  artery.  The  middle  and  posterior  cerebral,  and  verte- 
bral arteries  are  equally  liable  to  be  occluded  by  thrombosis. 

When  one  of  the  cerebral  arteries — the  left  middle  cerebral 
artery,  for  example — is  obstructed  close  to  the  circle  of  Willis, 
the  circulation  through  the  nutrient  arteries  supplied  by  it  to 
the  basal  ganglia  is  arrested,  and  as  these  are  terminal  arteries 
rapid  softening  occurs.  When  one  of  the  vessels  of  the  brain 
is  obstructed  on  the  cardiac  side  of  the  circle  of  Willis,  the  free 
anastomosis  of  the  latter  re-establishes  the  circulation  so  quickly 
that  no  pathological  changes  occur  in  the  brain.  If,  again,  the 
embolus  be  carried  forwards  past  the  basal  portion  to  the  arterial 
system  of  the  cortex,  it  is  quite  possible  that  the  free  anasto- 
mosis of  the  latter  may  prevent  decided  pathological  changes 
from  taking  place.  In  many  cases,  however,  a  certain  amount 
of  softening  does  occur  under  such  circumstances,  because  the 
anastomosis  is  not  always  so  free  as  to  compensate  for  the 
blocking  up  of  a  large  branch  of  the  artery.  When  the 
embolus  is  lodged  in  one  of  the  terminal  arteries  of  the  basal 
arterial  system  softening  always  occurs,  owing  to  the  absence 
of  anastomosis  with  neighbouring  arteries. 

The  first  effect  produced  by  occlusion  of  a  terminal  artery  is  oedema  of 
the  part  supplied  by  it.  The  venules  and  arterioles  of  the  part  are  imper- 
fectly nourished  so  that  their  walls  dilate  and  frequently  rupture,  giving 
rise  to  hypersemia  attended  by  cedematous  swelling  and  haemorrhage.  The 
tissues,  not  being  supplied  with  nourishment,  break  down  and  undergo 
softening.  When  the  softened  tissues  become  mixed  with  extravasated 
blo(^d,  they  give  rise  to  red  softening.  The  hypereemia  and  hemorrhage 
may  fail  to  occur,  and  then  simple  necrobiosis  results  from  the  occlusion 
of  the  vessel,  giving  rise  to  a  softened  mass  of  a  yellowish- white  or  white 
colour.  These  changes  generally  begin  in  the  course  of  the  second  twenty- 
four  hours  after  the  obstruction  has  occurred,  although  cases  are  reported 
in  which  the  consistence  of  the  brain  tissue  was  normal  after  the  lapse  of 
two  days. 


THE   NATURE   OF   THE   LESION.  517 

Microscopic  examination  reveals  the  presence  of  a  large  number  of 
reel  blood  corpuscles,  which  is  the  only  abnormal  appearance  observed 
during  the  first  twenty-four  hours.  At  a  later  period  the  nerve  elements 
undergo  gradual  degeneration.  The  most  prominent  microscopic  pecu- 
liarity consists  of  granular  corpuscles,  which  are  probably  derived  from 
degeneration  of  neuroglia  and  ganglion  cells  of  the  grey  substance,  and 
various  other  sources. 

Experi7nental  Investigations. — The  first  experimental  researches  with 
respect  to  the  embolic  process  was  undertaken  by  Virchow,  and  great 
additional  light  has  been  thrown  upon  the  subject  by  the  important  ex- 
perimental and  microscopic  investigations  of  Cohnheim.  Panum  studied 
experimentally  the  results  of  occlusion  of  cerebral  vessels  with  the  view  of 
determining  the  manner  in  which  death  is  caused.  B.  Cohn  investigated 
experimentally  various  clinical  and  anatomical  points  ;  Feltz  studied  the 
results  of  capillary  embolism  ;  while  Prevost  and  Ootard  made  a  series  of 
experiments  with  the  view  of  determining  the  relation  of  occlusion  of 
cerebral  vessels  to  softening. 

§  700.  Morbid  Physiology. — The  most  difficult  problem  to 
solve  with  respect  to  the  morbid  physiology  of  the  affection  is 
how  occlusion  of  only  one  of  the  cerebral  arteries  produces  loss 
of  consciousness.  Brown-Sequard  has  recently  dwelt  upon  the 
fact  that  local  lesions  exert  an  influence  over  remote  parts  of 
the  nervous  system,  and  the  sudden  arrest  in  the  circulation  in 
one  of  the  arteries  of  the  brain  is  likely  to  produce  widely- 
spread  effects.  Heubner  and  Duret  have  shown  that  although 
the  abundant  anastomoses  between  the  arteries  of  the  cortex 
after  a  time  establish  a  collateral  circulation,  yet  at  the 
moment  of  obstruction  great  disturbances  of  the  circulation 
and  marked  changes  in  pressure  may  occur  in  and  around  the 
implicated  region.  We  have  already  seen  that  sudden  depriva- 
tion of  nourishment  increases  the  irritability  of  nerve  fibres, 
and  it  is  probable  that  the  abrupt  arrest  of  the  arterial  circu- 
lation induces  a  powerful  outgoing  discharge  from  the  cortex. 
That  this  occurs  in  certain  cases  is  undoubted,  inasmuch  as 
the  onset  of  the  attack  is  marked  by  general  convulsions.  A 
powerful  discharge  of  this  kind  would  be  followed  by  exhaustion, 
and  temporary  loss  of  function,  or  in  other  words  the  attack 
would  be  characterised  by  loss  of  consciousness.  In  those  cases 
in  which  there  is  an  absence  of  convulsions  the  cortical  dis- 
charges may  be  supposed  to  neutralise  one  another  in  the 
nervous  system  without  producing  their  usual  visible  effects. 


518  FOCAL   DISEASES,   ACCOEDING  TO 

§  701.  Prognosis.  —  Both  embolism  and  thrombosis  are 
always  serious  affectioas.  When  embolism  occurs  in  a  young 
person  recovery  from  the  immediate  effects  may  be  rapid  and 
complete,  but  the  underlying  affection  to  which  the  attack  was 
due  will  still  be  present  and  may  cause  a  similar  attack  in 
the  future  or  give  rise  to  other  grave  symptoms.  Thrombosis 
is  usually  associated  with  advanced  age,  enfeeblement  of  the 
heart's  action,  and  degeneration  of  arteries,  and  during  the 
attack  there  is  great  danger,  however  slight  the  symptoms  ma}^ 
at  first  appear,  that  the  occlusion  will  become  more  and  more 
extensive. 

§  702.  Treatment.  —  Prophylactic  measures  can  only  be 
adopted  when  premonitory  symptoms  are  present  for  a  long  time 
in  connection  with  a  slowly-forming  thrombosis.  In  such  cases 
the  heart  should,  according  to  theory,  be  stimulated  by  digitalis, 
ammonia,,  and  alcoholic  stimulants ;  but  since  it  is  impossible 
to  diagnose  this  condition  during  life  from  hsemorrhage,  it  will 
be  better  to  be  content  with  adopting  the  same  treatment 
as  that  recommended  for  hsemorrhage.  During  the  stage  of 
coma  also  the  same  means  should  be  used  as  in  hsemorrhage. 

(6)  Thrombosis  of  the  Cerebral  Sinuses. 
.§  703.  History. — Special  attention  was  first  directed  to  the  subject  of 
thrombosis  of  the  cerebral  sinuses  by  the  observations  of  Tonnele.  Many 
valuable  clinical  observations  with  regard  to  the  disease  were  made  by 
Puchelt,  and  the  attention  of  Lebert  was  also  directed  to  it.  The  treatises 
of  Von  Dusch,  B.  Cohn,  and  of  Lancereaux  helped  greatly  to  extend  and 
to  systematise  our  knowledge  with  respect  to  this  thrombosis ;  and  in 
more  recent  times  our  knowledge  has  been  further  increased  by  the 
labours  of  Gerhardt,  Griesinger,  Corazza,  Heubner,  and  Hugnenin. 

§  704.  Etiology. — Thrombosis  of  the  sinuses  may  be  divided 
into  two  groups :  the  first  comprising  the  cases  which  arise  in 
the  absence  of  any  affection  of  the  walls  of  the  veins,  and  the 
second  those  which  originate  from  phlebitis. 

The  cases  of  the  first  group  arise  in  conditions  oi 'marasmus , 
in  which  the  quality  of  the  blood  is  altered  and  the  circulation 
enfeebled.  Under  such  circumstances  coagulation  of  the  blood 
is  specially  prone  to  occur  in  the  sinuses,  inasmuch  as  they  are 


THE   NATURE   OF   THE   LESION.  519 

rigid  tubes  and  incapable  of  collapsing  ;  they  are  also  destitute 
of  muscular  walls,  and  are  traversed  by  bands  of  connective 
tissue. 

Thrombosis  of  the  sinuses  from  marasmus  is  particularly 
apt  to  occur  in  children,  especially  during  the  first  six  months 
of  life,  when  they  are  liable  to  suffer  from  collapse  induced  by 
severe  diarrhoea.  It  also  occurs  in  adults,  in  consequence  of 
profuse  suppuration,  cancer,  senile  marasmus,  and  other  con- 
ditions of  debility.  This  form  of  thrombosis  occurs  wdth  special 
frequency  in  the  longitudinal  and  lateral  sinuses.  Obstruc- 
tion to  the  return  of  the  venous  blood  towards  the  heart 
increases  the  liability  to  the  formation  of  thrombosis  of  the 
sinuses,  but  it  is  not  likely  that  venous  stasis  can  give  rise  to 
it  in  the  absence  of  other  favouring  conditions. 

The  second  group  of  thromboses  is  caused  by  inflammation 
of  the  sinuses,  the  result  generally,  probably  always,  of  disease 
or  injury  of  the  cranial  bones.  Caries  of  the  petrous  portion 
of  the  temporal  bone  is  by  far  the  most  common  cause  of 
inflammation  of  the  sinuses ;  the  lateral  and  petrosal  sinuses, 
which  lie  in  the  vicinity  of  the  temporal  bone,  are  then 
particularly  liable  to  be  affected,  although  the  process  may 
implicate  the  circular  and  cavernous  sinuses  as  well  as  the 
upper  part  of  the  internal  jugular  vein.  In  most  cases  a  real 
phlebitis  is  induced,  followed  by  the  formation  of  purulent 
thrombi.  Thrombosis  of  the  sinuses  also  frequently  follows 
blows  on  the  head,  or  inflammatory  conditions  of  the  scalp 
and  cranial  bones.  Erysipelas  of  the  head  and  face,  and 
furunculus  of  the  face,  especially  of  the  upper  lip  and  fore- 
head, not  unfrequently  give  rise  to  thrombosis  of  the  sinuses. 
Cohn  observed  a  case  in  which  suppurative  phlebitis  of  the 
cavernous  sinuses  occurred  in  connection  with  purulent  inflam- 
mation of  the  deep  muscles  of  the  neck. 

§  705.  Symptoms. — The  symptoms  of  thrombosis  of  the 
cerebral  sinuses  are  generally  marked  by  complicating  diseases, 
so  that  it  is  rarely  possible  to  diagnose  the  affection  during 
life.  The  symptoms  also  vary  greatly,  both  according  to  the 
seat  of  the  occlusion  and  according  as  the  thrombosis  is  or  is 
not  the  result  of  phlebitis. 


520  FOCAL  DISEASES,   ACCORDING  TO 

Thrombosis  of  the  sinuses  in  children  almost  always  arises 
during  the  marasmus,  caused  by  exhausting  diarrhoea,  and  the 
symptoms  produced  are  the  same  as  those  of  cerebral  anaemia, 
being  such  as  Dr.  Marshall  Hall  described  under  the  name  of 
hydrencephaloid  disease.  In  addition  to  the  collapse,  somno- 
lence, and  coma  of  pure  cerebral  anaemia,  motor  disorders,  as 
convulsions  or  paralysis,  are  generally  present.  Rigidity  of  the 
muscles  of  the  neck,  sometimes  also  of  those  of  the  back  and 
even  of  the  limbs,  occasionally  nystagmus,  strabismus,  ptosis, 
and  paresis  of  the  facial  muscles  have  been  observed. 

Thrombosis  of  the  sinuses  resulting  from  marasmus  in  adults 
gives  rise  to  very  various  and  indefinite  symptoms,  and  at  times 
a  slight  degree  of  apathy  and  general  depression  are  the  only 
symptoms  observed.  The  patient  at  the  outset  may  complain 
of  headache,  nausea,  and  vomiting,  but  these  soon  give  place 
to  coma,  while  in  a  few  cases  loss  of  consciousness  may  be  pre- 
ceded by  delirium,  which  may  assume  a  maniacal  character. 
The  condition  of  the  pupils  is  variable. 

Motor  disturbances  are  usually  present,  the  most  usual  being 
strabismus,  trismus,  contractures  which  may  involve  one-half  of 
the  body,  or  both  legs  and  both  arms,  tremors,  and  epileptiform 
convulsions,  either  limited  to  one  or  involving  the  four  extremi- 
ties. The  motor  disorders  may  assume  the  form  of  paresis  or 
paralysis,  which  may  be  limited  to  the  facial  nerve  or  to  the 
motor  oculi,  or  may  involve  one-half  or  both  sides  of  the  body. 
At  other  times  both  paralysis  and  convulsions  may  be  asso- 
ciated, one  extremity  being  the  seat  of  contracture  and  the 
other  of  paralysis.  These  symptoms  may,  however,  be  present 
in  cases  of  cerebral  ansemia  or  of  venous  hypersemia  of  the 
brain. 

A  valuable  sign  of  the  disease  is  sometimes  afforded  by 
swelling  of  the  veins  outside  the  skull  which  are  in  commu- 
nication with  the  obstructed  sinus.  The  superior  longitudinal 
sinus,  for  instance,  communicates  directly  with  the  veins  of  the 
nasal  cavities  and  with  those  on  the  upper  surface  of  the  skull. 
The  occurrence  of  epistaxis,  therefore,  favours  the  idea  of 
obstruction  of  this  sinus,  and  in  children  the  presence  of 
distended  vessels  running  to  the  anterior  fontanelle  from  the 
neighbourhood  of  the  temples  and  ears  on  both  sides  of  the 


THE   NATURE   OF   THE   LESION.  521 

head  also  favours  the  same  view.  Cyanosis  of  the  face  limited 
to  the  part  supplied  by  the  anterior  facial  veins  is  also,  according 
to  Gerhardt,  of  diagnostic  significance. 

The  lateral  sinus  communicates  with  a  small  vein  which 
traverses  the  mastoid  process,  and  in  thrombosis  of  the  sinus 
localised  oedema  behind  the  ear  may  make  its  appearance. 
This  sign  is  occasionally  valuable,  but  is  rarely  met  with. 
Simultaneous  occlusion  of  both  lateral  sinuses  gives  rise  to  the 
same  symptoms  as  occlusion  of  the  superior  longitudinal  sinus. 

The  cavernous  sinus  communicates  with  the  ophthalmic 
veins,  and  in  thrombosis  of  this  sinus  venous  hypersemia  of  the 
fundus  oculi  has  been  observed,  as  well  as  oedema  of  the  eye- 
lids and  conjunctiva  and  prominence  of  the  eyeballs,  due  to 
congestion  of  the  retrobulbar  veins  and  of  the  frontal  vein. 
Paralysis  of  the  motor  nerves  of  the  eye,  trigeminal  neuralgia, 
and  neuroparalytic  ophthalmia  may  also  be  present,  owing  to 
the  disturbance  in  the  nutrition  of  the  nerves  which  pass  along 
the  side  of  the  cavernous  sinus. 

In  thrombosis  of  the  sinuses  in  infants  the  fontanelle  is 
depressed,  and  at  times  the  edges  of  the  bones  pushed  one  over 
the  other  ;  but  during  the  progress  of  the  disease  the  fontanelle 
may  again  become  tense  and  prominent,  and  the  cranial  bones 
pressed  apart  (Gerhardt).  This  increase  of  the  contents  of  the 
skull  is  caused  either  by  effusion  of  serum  from  the  tense  veins 
giving  rise  to  a  species  of  hydrocephalus  or  to  extensive 
meningeal  or  intra- cerebral  hemorrhage  resulting  from  throm- 
bosis of  the  sinuses. 

The  phlehitic  variety,  as  already  remarked,  is  generally 
caused  by  otitis  interna  or  injuries  to  the  head.  These  affec- 
tions also  give  rise  to  meningitis  and  cerebral  abscesses  as 
well  as  to  purulent  thrombosis,  and  inasmuch  as  these  patho- 
logical conditions  are  frequently  combined,  it  is  very  difficult 
to  distinguish  clinically  between  them.  In  a  few  reported 
cases,  however,  suppurative  thrombosis  was  alone  present 
uncomplicated  by  meningitis  or  by  lesions  of  the  cerebral  sub- 
stance. The  affection  sometimes  pursues  a  latent  course,  and 
is  only  discovered  after  death.  The  symptoms  are  usually 
similar  to  those  observed  in  cases  of  septicaemia  with  specially 
prominent  cerebral  symptoms.     The  attack  frequently  begins 


522  FOCAL  DISEASES,   ACCORDING  TO 

with  chilliness,  which  generally  recurs  repeatedly  during  the 
course  of  the  disease,  and  the  patient  has  a  characteristic  typhoid 
look,  with  dry  tongue,  loss  of  appetite,  and  mental  confusion. 
After  a  time  the  patient  falls  into  a  somnolent  condition,  which 
gives  place  to  complete  coma,  terminating  in  death.  Mild 
delirium  is  present  in  a  few  cases,  and  more  rarely  the  delirium 
assumes  an  active  form. 

Suppurative  thrombosis  is  frequently  associated  with  motor 
and  sensory  disturbances  caused  by  the  accompanying  menin- 
gitis. These  consist  of  pain  in  the  head,  hyperalgesia,  paresis, 
paralysis,  and  convulsions. 

§  706.  Diagnosis. — When  a  patient,  suffering  from  caries  of 
the  internal  ear,  furunculus  in  the  face,  or  who  has  received  an 
injury  to  the  head,  develops  symptoms  like  those  of  pyaemia, 
with  marked  disturbance  of  the  cerebral  functions,  purulent 
thrombosis  of  the  sinuses  may  be  suspected.  The  diagnosis 
will  be  further  corroborated  by  the  disturbances  of  the  circu- 
lation, which  have  already  been  described  from  the  thrombosis. 

§  707.  Course  and  Prognosis. — The  duration  of  the  disease 
is  difficult  to  determine,  and  it  may  probably  extend  occasionally 
over  several  weeks,  although  usually  terminating  in  a  much 
shorter  time. 

The  prognosis  is  very  unfavourable,  but  recovery  is  said, 
occasionally  to  take  place  (Sddillot,  Lebert,  and  Griesinger). 

§  708.  Morbid  Anatomy. — Any  sinus  may  become  the  seat 
of  thrombosis,  but  some  of  them  are  much  more  liable  to  be 
affected  than  others.  The  superior  longitudinal  sinus  is  the 
one  which  is  usually  implicated  in  cases  of  thrombosis  from 
marasmus,  and  the  sinuses  in  the  neighbourhood  of  the  petrous 
bone  in  the  phlebitic  variety.  The  veins  which  empty  them- 
selves into  the  sinuses  become  enlarged  and  gorged  with 
blood,  and  are  often  filled  with  thrombotic  masses,  so  that  they 
look  like  large  earthworms  when  lying  on  the  surface  of  the 
brain.  Ruptures  of  the  vessels  not  unfrequently  occur,  causing 
meningeal  haemorrhage,  but  sometimes  consists  only  of  small 
hsemorrhagic  spots,  while  at  other  times  may  amount  to  pro- 


THE   NATURE   OF   THE   LESION.  523 

fuse  hsemorrhage.  The  cortex  of  the  brain  is  also  frequently 
the  seat  of  capillary  haemorrhages,  and  Lancereux  has  described 
small  spots  of  softening.  The  phlebitic  variety  is  frequently 
accompanied  by  meningitis,  caused  by  the  primary  lesion. 

§  709.  Treatment. — No  treatment  has  hitherto  been  found 
of  any  avail. 

(c)  Occlusion  of  the  Cerebral  Capillaries. 

§  710.  Experimental  investigations  have  shown  that  marked 
disturbances  of  the  cerebral  functions  may  be  caused  by  occlusion 
of  the  cerebral  capillaries,  and  clinical  records  also  point  to  the 
same  conclusion. 

§  711.  Etiology. — In  severe  cases  of  malarial  and  intermit- 
tent fever  the  cerebral  capillaries  are  liable  to  be  obstructed  by 
dark  masses,  a  condition  which  has  been  called  pigment  em- 
bolism. The  cerebral  capillaries  may  also  be  obstructed  by 
drops  of  fat.  The  fat  is  usually  swept  into  the  blood  current 
by  the  breaking  up  of  atheromatous  formations  in  the  interior 
of  the  larger  blood-vessels.  In  cases  of  injury  to  bone  the 
fatty  tissue  of  the  marrow  may  be  carried  into  the  blood-vessels, 
giving  rise  to  emboli  in  the  lungs  and  possibly  in  the  brain. 

Chorea  has  been  supposed  to  be  due  to  capillary  embolism, 
but  the  subject  will  be  subsequently  discussed.  The  cerebral 
capillaries  are  said  to  be  occluded  by  lime  becoming  deposited 
in  their  walls,  a  process  named  by  Virchow  lime  metastasis. 
Some  disease  of  bone  is  usually  associated  with  this  condition, 
and  Virchow  thinks  that  the  lime  is  first  absorbed  from  the 
diseased  bone,  and  afterwards  deposited  in  the  vessels. 

§  712.  Symptoms. — The  experiments  of  Feltz,  and  of  Provost 
and  Cotard  show  that  extensive  embolism  of  very  fine  particles 
may  rapidly  induce  death  in  animals  by  causing  diffuse  ansemia 
of  the  brain.  Nothing  analogous  to  this  is  known  to  take  place 
in  diseased  conditions.  If  the  embolic  masses  are  few  the 
symptoms  which  they  give  rise  to  are  so  slight  as  not  to  be 
recognisable  during  life.  Such  is  known  to  be  the  case  in 
certain  instances  of  fat  embolism.     In  other  cases  a  considerable 


524  FOCAL   DISEASES. 

territory  of  the  brain  may  be  suddenly  deprived  of  its  nutriment, 
and  apoplectic  symptoms  may  then  be  produced,  followed  by  the 
usual  symptoms  of  a  localised  cerebral  disease. 

The  symptoms,  however,  are  usually  such  as  arise  from 
diffused  cerebral  disease,  the  more  common  of  them  being 
dizziness,  headache,  nausea,  trembling,  and  weakness  in  the 
extremities,  and  mental  disturbance,  as  marked  loss  of  memory 
and  other  signs  of  mental  decay. 

§  713.  Morbid  Anatomy. — Capillary  occlusions  are,  of  course, 
only  to  be  detected  with  the  microscope.  Delacour  says  that 
in  cases  of  lime  metastasis  a  resistance  is  felt  to  the  knife  in 
cutting  through  the  brain,  and  rough  prominences  may  be  felt 
on  the  surface  with  the  finger. 

The  nature  of  the  secondary  changes  in  the  brain  varies 
according  to  the  number  of  the  vessels  obstructed,  and  it  is 
only  when  a  large  number  are  occluded  that  disturbance  of  the 
circulation  will  not  be  compensated,  structural  changes  then 
occurring  analogous  to  those  following  obstruction  of  the  large 
arteries.  Experimental  investigation  has  shown  that  the  first 
effect  of  the  occlusion  is  to  cause  ana3mia,  and  in  the  further 
progress  of  the  affection  the  various  stages  of  necrobiosis  may 
supervene,  ending  in  complete  softening.  The  centres  of 
softening  are  often  of  small  size,  but  several  are  usually 
present. 

§  714.  The  course  and  prognosis  depend  upon  the  extent 
and  nature  of  the  occlusion.  Isolated  capillary  embolisms  are 
of  no  significance ;  but  if  they  are  numerous  the  resulting  dis- 
turbances are  in  every  respect  similar  to  the  corresponding 
secondary  effects  of  the  occlusion  of  the  larger  arteries. 

§  715.  Treatment. — The  treatment  must  be  conducted  on 
general  principles. 


525 


CHAPTER  IV. 


(I.)  GENERAL  CONSIDERATION  OF  FOCAL  DISEASES, 
ACCORDING  TO  THE  NATURE  OF  THE  LESION 
(Continued). 


I 


2.   INTRACRANIAL    HEMORRHAGE. 

Intracranial  hsemorrhage  may  be  divided  into  {a)  cerebral, 
and  (6)  meningeal  hsemorrhage. 

{a)  Cerebral  Haimorrhage. 
§  716.  Definition. — By  cerebral  hsemorrhage  is  here  meant 
an  extravasation  of  blood  into  the  substance  of  the  encephalon 
or  into  the  ventricles  of  the  brain. 

§  717.  Histo7-y. — Hsemorrhage  into  the  substance  of  the  encephalon  is 
frequently  termed  apoplexy.  The  word  iiroTrAijao-w  means  "  I  strike  down," 
and  a  j)erson  who  had  suddenly  fallen  down  insensible  was  said  to  be  in  a 
condition  of  iTroTrAij^ta.  It  was  pointed  out  by  Wepfer  that  this  condition 
was  frequently  caused  by  cerebral  hsemorrhage,  and  after  a  time  the  name 
of  the  group  of  symptoms  which  signified  sudden  iinconsciousness  was 
transferred  to  the  anatomical  condition  which  was  the  most  frequent  cause 
of  that  occurrence.  The  process  did  not  stop  here  ;  during  the  coiu-se  of 
investigation  it  was  seen  that  hsemorrhage  into  the  substance  of  other 
organs  was  not  uncommon,  and  after  a  time  the  meaning  of  the  term  was 
extended  so  as  to  include  these  haemorrhages  also.  The  term  therefore 
having  come  to  signify  conditions  so  different,  it  will  be  well  to  avoid 
its  use  as  much  as  possible. 

§  718.  Etiology. — The  circumstances  which  predispose  to 
cerebral  hsemorrhage  are — (1)  Disease  of  the  vessels,  (2)  In- 
crease of  the  arterial  tension,  (3)  Disease  of  the  tissues 
surrounding  the  vessels,  and  (4)  Certain  diseases  of  the  blood 
itself. 


526  FOCAL   DISEASES,  ACCORDING   TO 

(1)  Disease  of  the  Vessels. — The  great  majority  of  massive  haemorrhages 
into  the  substance  of  the  brain  are  due  to  fatty  degeneration  of 
branches  of  the  Sylvian  artery,  which  pass  through  the  anterior 
perforated  space  to  reach  the  corpus  striatum.  Fatty  degeneration  of 
arteries  may  be  primary  or  secondary.  Primary  fatty  degeneration 
is  a  passive  process,  not  being  preceded  by  any  increased  nutritive 
activity  of  the  affected  parts,  but  the  secondary  form  of  the  process 
is  preceded  by  an  inflammatory  cellular  infiltration  of  the  sub- 
endothelial  connective  tissue  of  the  vessels,  and  constitutes  atheroma. 
It  was  formerly  believed  that  when  the  arteries  at  the  base  of  the 
brain  were  found  in  a  condition  of  atheromatous  degeneration  the 
existence  of  a  similar  condition  of  the  vessels  in  the  interior  of  the 
brain  might  be  inferred,  and  that  intracerebral  haemorrhages  might 
in  most  instances  be  attributed  to  the  brittleness  of  the  vessels. 
The  behef  is  now  growing  that  the  influence  of  atheromatous  disease 
in  the  causation  of  cerebral  haemorrhage  is  indirect  rather  than  direct. 
Atheroma  of  the  vessels  may  occasionally  lead  to  aneurisms  of  the  larger 
vessels  at  the  base  of  the  brain,  but  they  are  not  often  the  cause  of 
hsemorrhage.  Besides,  rupture  of  an  aneurism  of  one  of  the  larger  vessels 
would  give  rise  to  haemorrhage  between  the  meninges,  and  not  into  the 
substance  of  the  brain.  Atheromatous  degeneration  may,  however,  cause 
haemorrhage  indirectly  by  rendering  the  walls  of  the  larger  vessels  rigid, 
so  that  the  pulse  wave  reaches  the  arterioles  without  being  modified  by 
the  normal  elasticity  of  the  arteries. 

By  far  the  most  frequent  cause  of  intracerebral  haemorrhage  is  that 
condition  of  the  arterioles  which  has  been  described  by  Charcot  and 
Bouchard  as  miliary  aneurisms.  These  aneurisms  are  situated  on  the 
arterioles,  are  of  a  reddish  colour,  and  vary  in  size  from  that  of  a  millet- 
seed  to  a  pin's  head.  Sometimes  a  few  only  are  found  in  the  vicinity  of 
the  ruptm-ed  vessel,  while  at  other  times  they  are  scattered  in  large 
numbers  throughout  the  whole  brain.  The  parts  of  the  brain  in  which 
they  are  situated,  taken  in  the  order  of  their  decreasing  frequency,  are 
the  lenticular  nucleus,  the  optic  thalami,  the  pons,  the  convolvitions,  the 
caudate  nucleus,  the  cerebellum,  the  medulla  oblongata,  the  middle 
peduncles  of  the  cerebellum,  and  the  centrum  ovale. 

Mihary  aneurisms  occur  rarely  before  the  fortieth  year,  but  are  found 
with  increasing  frequency  after  that  age.  They  result,  according  to 
Charcot  and  Bouchard,  from  a  kind  of  arterial  sclerosis  of  the  nature  of  a 
chronic  periarteritis.  This  alteration  consists  in  multipKcation  of  the 
nuclei  of  the  lymph-sheaths  and  adventitia,  a  process  which  is  generally 
accompanied  by  atroj)hy  of  the  muscular  coat.  When  atrophy  of  the  latter 
occurs  without  a  compensatory  thickening  of  the  adventitia,  rupture  of 
these  aneurisms  very  readily  takes  place. 

The  part  which  primary  fatty  degeneration  of  the  vessels  plays  in  the 
causation  of  cerebral  haemorrhage  has  been  insisted  upon  by  Paget.  This 
condition  of  the  vessels  is  found  at  all  ages,  and  in  cachectic  children  even 


THE   NATURE   OF   THE  LESION.  527 

more  frequently  than  among  aged  persons,  so  that  care  must  be  taken  not 
to  over-estimate  its  influence  in  the  production  of  haemorrhage.  Billroth 
has  also  shown  that  in  a  large  nximber  of  cases  this  form  of  fatty  degenera- 
tion of  the  small  vessels  is  secondary  to  disease  of  the  nervous  tissues. 
Even  after  making  these  deductions  from  its  importance  as  a  predisposing 
cause,  there  can  be  no  doubt  that  this  condition  does  increase  the  hability 
to  cerebral  haemorrhage. 

(2)  Vascular  Tension. — It  is  very  doubtful  whether  increase  of  the 
arterial  tension  ever  gives  rise  to  cerebral  haemorrhage  without  disease  of 
the  vascular  walls;  but  when  the  latter  are  degenerated  then  sudden 
increase  of  tension  becomes  a  powerful  predisposing  cause  of  haemorrhage. 
Sudden  exposure  to  cold  may  increase  the  arterial  tension  by  inducing  ex- 
tensive contraction  of  the  cutaneous  arteries.  During  the  winter  months 
it  is  very  common  for  individuals  to  be  found  in  an  apoplectic  condition  on 
the  streets,  and  taken  up  by  the  police  supposed  to  be  drunk.  Such  cases 
occur  usually  in  persons  beyond  middle  age,  their  breath  may  smell  of 
alcohol,  and  they  may  even  be  known  to  have  been  drinking  during  the 
evening.  The  evening  has  been  spent  in  a  heated  apartment,  where,  under 
the  conjoined  influence  of  a  high  temperature,  alcohol,  and  emotional 
excitement  of  various  kinds,  the  cutaneous  vessels  have  become  dilated,  the 
skin  bathed  in  perspiration,  and  the  cardiac  action  increased.  On  going 
out  into  the  cold  air  the  surface  becomes  suddenly  chilled,  the  cutaneous 
vessels  contract,  the  arterial  tension  becomes  immediately  greatly  in- 
creased, the  internal  organs  become  gorged  with  blood,  and  if,  as  is 
frequently  the  case,  the  walls  of  the  cerebral  vessels  are  weakened  by 
disease,  rupture  takes  place  (Fothergill). 

The  hypertrophy  of  the  left  ventricle  which  is  associated  with  con- 
tracted kidney  takes  a  more  active  part  in  the  production  of  cerebral 
haemorrhage.  Avoiding  as  much  as  possible  controversial  points,  it  is 
beyond  question  that  contracted  kidney  is  associated  with  a  general  con- 
dition in  which  the  walls  of  the  arterioles  of  the  entire  body  become 
thickened,  inelastic,  and  the  lumina  of  the  vessels  themselves  much  dimi- 
nished in  size.  This  condition  greatly  obstinicts  the  flow  of  blood  from 
the  heart  towards  the  capillaries,  and  the  left  ventricle  becomes  the 
subject  of  compensatory  hypertrophy,  with  the  effect  of  producing  a 
permanent  increase  in  the  arterial  tension.  And  whatever  may  be  the 
nature  of  the  primary  change  in  the  arteries,  whether  a  hypertrophy  of 
the  muscular  coat,  or  sclerosis  of  the  external  coat,  or  both  combined,  the 
walls  of  the  vessels  undergo  in  long-standing  cases  degenerative  changes 
which  render  them  brittle  and  easily  ruptured. 

Obstruction  to  the  return  of  the  venous  blood  from  the  brain  probably 
also  predisposes  to  haemorrhage,  but  its  direct  effect  must  be  small. 
The  obstruction  may  be  temporary  or  permanent.  Temporary  in  such 
actions  as  coughing,  sneezing,  laughing,  or  straining  at  stool,  and  per- 
manent in  affections  of  the  mitral  and  tricuspid  valves,  obliteration 
and  compression  of  the  cerebral  sinuses,  compression  of  the  jugulars  and 


528  FOCAL   DISEASES,   ACCORDING  TO 

superior  vena  cava,  and  affections  of  the  lungs  as  emphysema  and  fibroid 
phthisis. 

(3)  Condition  of  the  Tissioes. — Rochoux  advanced  the  theory  that  spon- 
taneous haemorrhage  is  generally  preceded  by  a  process  of  softening  of  the 
cerebral  tissue,  to  which  he  gave  to  this  process  the  name  of  ramollissement 
hemorrhagipare.  In  consequence  of  the  change  of  consistence  of  the 
nervous  tissue,  the  small  vessels  lose  their  natural  support,  and  become 
unable  to  resist  the  pressure  of  the  blood.  It  is  now  generally  beheved 
that  the  softening  is  a  secondary  process,  the  result  partly  of  the  imbi- 
bition of  blood  serum,  and  j)artly  of  inflammation  excited  by  the  ex- 
travasation in  the  sui'rounding  tissues.  Haemorrhage  may,  however,  occur 
as  a  result  of  softening  of  the  tissues  in  cases  of  embohsm  and  thrombosis, 
but  this  condition  will  be  noticed  hereafter.  Some  authors  think  that 
haemorrhage  is  due  occasionally  to  atrophy  of  the  cerebral  substance,  and 
believe  that  the  vessels  then  rupture  in  consequence  of  their  becoming 
dilated  in  order  to  fill  the  vacuum.  Bu.t  the  reduction  in  the  size  of  the 
brain  proceeds  far  too  slowly  for  much  dilatation  of  the  vessels  to  result 
from  it ;  and  the  atrophy  is  compensated  to  some  extent  by  thickening  of 
the  skull  and  increase  in  the  size  of  the  frontal  sinuses,  but  chiefly  by 
increase  of  the  cerebro-spinal  fluid. 

(4)  State  of  the  Blood. — Various  diseases,  the  essential  condition  of 
which  apjpears  to  be  caused  by  some  change  in  the  composition  of  the 
blood,  occasionally  lead  to  cerebral  haemorrhage.  Cerebral  haemorrhages 
have  been  observed  in  pyaemia,  in  the  typhoid  state,  scorbutus,  j)urpura, 
chlorosis,  leucocythaemia,  pernicious  anaemia,  and  icterus,  but  are  excep- 
tionally met  with  in  these  diseases. 

§  719.  Other  Predisposing  Causes — Some  families  exhibit 
a  predisposition  to  cerebral  hsemorrhage,  hence  it  has  been 
assumed  that  the  disease  is  hereditary.  The  action  of  heredity 
in  predisposing  to  haemorrhage  is,  however,  only  an  indirect 
result  of  the  inherited  tendency  to  arterial  degeneration.  It 
was  formerly  believed  that  some  individuals  inherited  an  apop- 
lectic constitution.  This  was  supposed  to  be  characterised  by 
broad  chest,  short  neck,  large  abdomen,  powerful  muscular 
system,  and  florid  complexion.  Exact  statistics,  however,  prove 
that  cerebral  heemorrhage  does  not  spare  any  constitution, 
and  that  poorly-nourished,  thin  persons  are  as  frequently 
attacked  as  the  plethoric. 

One  of  the  most  important  predisposing  causes  of  the  disease 
is  age.  Cerebral  hsemorrhage  is  rare  before  the  fortieth  year, 
relatively  frequent  afterwards.  It  must  not  be  forgotten  that 
the  disease  attacks  young  persons,  and  it  has  been  observed  in 


THE   NATURE   OF   THE   LESION,  529 

infants  and  even  at  birth.    Meningeal  hsemorrhage  is  relatively 
common  in  early  childhood. 

Sex  undoubtedly  exercises,  a  certain  degree  of  influence  in 
predisposing  to  cerebral  haemorrhage,  probably  owing  to  the 
fact  that  men  are  more  frequently  exposed  to  the  exciting 
causes  of  the  disease.  The  proportionate  frequency  with  which 
men  and  women  are  attacked  has  been  variously  estimated  by 
different  authors,  but  it  may  safely  be  asserted  that  the  ratio 
of  2"1  rather  under  than  overstates  the  proportion. 

The  influence  of  occupation  in  predisposing  to  cerebral 
haemorrhage  has  not  yet  been  satisfactorily  determined,  and  the 
same  may  be  said  with  regard  to  the  influence  of  climate,  since 
the  immunity  from  the  disease  once  attributed  to  warm  climates 
has  recently  been  called  in  question.  In  Europe  the  disease  is 
most  common  in  winter,  then  in  autumn  and  spring,  and  least 
so  in  summer.  Altitude  appears  to  exert  some  influence  in  the 
production  of  the  affection,  since  it  is  very  common  in  the 
elevated  regions  of  Mexico,  of  the  Cordilleras,  and  the  Andes. 
Certain  substances,  as  alcohol,  predispose  to  haemorrhage  by 
inducing  fatty  degeneration  of  the  vessels. 

§  720.  Symptoms. — The  symptoms  vary  greatly  according  to 
the  situation  and  extent  of  the  lesion  ;  but  the  mode  of  onset 
being  sudden  and  the  lesion  of  a  destructive  character,  the 
initial  group  of  symptoms  bear  a  general  similarity  to  each 
other  in  all  cases. 

1.  PreWjOnitory  Symptoms.  —  The  attack  is  frequently 
ushered  in  without  any  premonitory  symptoms,  and  in  no 
instance  can  any  symptom  be  relied  upon  as  an  invariable 
antecedent  of  hsemorrhage.  Premonitory  symptoms  may,  how- 
ever, manifest  themselves  days  and  even  weeks  before  the 
actual  onset  of  the  attack,  and  these  are  no  doubt  frequently 
caused  by  rupture  of  minute  vessels  prior  to  the  graver  event 
which  ushers  in  the  apoplectic  condition.  The  usual  fore- 
runners of  the  apoplectic  attack  are  dizziness,  headache,  ringing 
in  the  ears,  muscas  volitantes,  numbness  in  the  hand  or  foot, 
muscular  twitchings  of  the  face  or  of  some  portion  of  the 
upper  or  lower  limbs,  especially  of  the  fingers  or  toes,  mistakes 
in  talking  or  writing,  vomiting,  mental  irritability  and  drowsi- 
11 


530  FOCAL   DISEASES,  ACCORDING  TO 

ness.  These  symptoms  may  appear  separately  or  variously 
combined,  and  although  all  of  them  may  occur  without  being 
followed  by  an  apoplectic  attack,  yet  in  the  old  and  middle 
aged,  especially  when  the  arteries  are  degenerated,  they  should 
be  regarded  as  warnings. 

2.  Modes  of  Onset. — For  facility  of  description  the  mode  of 
onset  of  cerebral  haemorrhage  may  be  divided  into  three  prin- 
cipal classes:  (i.)  The  apoplectiform  onset;  (ii.)  the  epileptiform 
onset ;  and  (iii.)  the  simple  mode  of  onset  (Bastian). 

(i.)  Apoplectiform  Onset — This  mode  of  onset  is  characterised 
by  sudden  loss  of  consciousness  with  resolution  of  the  limbs,  and 
what  is  popularly  termed  "apoplexy."  In  a  small  number  of 
cases  the  onset  may  be  instantaneous.  In  the  midst  of  apparent 
health  the  patient  may  fall  insensible  to  the  ground.  In  such 
cases  the  lesion,  which  need  not  necessarily  be  large,  is  usually 
found  in  the  pons  or  medulla.  The  attack  usually  begins  more 
gradually.  The  patient  suffers  from  dizziness,  abnormal  sen- 
sations or  pain  in  the  head,  mental  confusion,  difficulty  of 
speech,  drowsiness,  nausea  and  vomiting,  or  a  sense  of  great 
exhaustion ;  and  after  some  of  these  symptoms  have  con- 
tinued for  a  few  minutes  or  longer  the  stage  of  unconsciousness 
comes  on. 

When  the  apoplectic  attack  is  well  marked  the  patient  lies 
in  a  state  of  profound  coma,  and  is  insensible  to  all  kinds  of 
stimuli.  The  face  is  usually  flushed  and  swollen,  though  occa- 
sionally it  may  be  pale  and  clammy,  the  lips  are  livid,  the  head 
and  neck  feel  warm  and  are  bathed  in  perspiration,  the  carotids 
and  other  arteries  throb  violently,  the  eyelids  are  closed,  the 
conjunctivae  injected,  the  eyeballs  fixed,  the  pupils  sluggish  to 
light,  the  respiration  is  usually  deep,  with  or  without  ster- 
torous inspiration  and  protrusion  of  the  cheeks  during  ex- 
piration, the  pulse  is  generally  full  and  slow,  and  there  is  either 
complete  muscular  resolution,  so  that  the  limbs  when  raised 
drop  like  inert  bodies,  or  the  resolution  is  more  marked  on  one 
side  of  the  body  than  on  the  other.  In  the  severest  cases 
there  is  not  only  complete  absence  of  voluntary  motion,  but 
all  the  reflex  movements  are  abolished,  with  the  exception  of 
the  cardiac  and  respiratory  movements,  and  those  concerned  in 


THE   NATURE   OF   THE   LESION.  531 

deglutition,  the  latter  being  generally  retained  as  regards  the 
pharynx  and  oesophagus. 

When  this  condition  has  been  brought  about  by  a  severe 
lesion  of  the  brain,  the  patient  may  die  after  a  few  minutes,  a 
few  hours,  or  a  few  days.  In  the  slighter  forms,  however, 
the  apoplectic  state  may  last  only  a  short  time,  and  then 
gradually  give  place  to  other  related  symptoms.  When  the 
coma  is  not  very  profound,  powerful  irritations  cause  reflex 
movements,  and  in  the  lesser  degrees  of  the  apoplectic  state, 
the  patient,  when  loudly  spoken  to,  raises  his  eyelids  for  a 
moment  or  two,  and  may  even  reply  in  a  monosyllable  when 
loudly  pressed  with  any  question.  In  such  cases  a  difference 
can  be  detected  between  the  two  halves  of  the  body;  the  ex- 
tremities of  one  side  offer  a  certain  resistance  to  passive 
motion,  while  those  of  the  other  sink,  when  unsupported,  like 
inert  masses ;  the  corner  of  the  mouth  on  one  side  is  lower 
than  on  the  other,  and  the  opposite  naso-labial  fold  is  strongly 
marked. 

(ii.)  The  Epileptiform  Onset. — The  epileptiform  is  a  mere 
variety  of  the  apoplectiform  mode  of  onset.  The  patient, 
either  with  or  without  prodromata,  drops  down  insensible  in  a 
kind  of  epileptic  fit,  and  after  a  time  it  is  discovered  that  the 
patient  is  paralysed  on  one  side  of  the  body.  Temporary 
hemiplegia  may  follow  severe  attacks  of  unilateral  convulsions 
due  to  a  molecular  lesion  of  the  cortex,  but  in  the  cases  under 
present  consideration,  the  hemorrhage  destroys  a  certain  por- 
tion of  the  brain,  and  the  paralysis  initiated  is  more  or  less 
persistent.  Although  prodromata  may  be  absent  altogether, 
yet  the  epileptic  attack  is  very  frequently  preceded  either  by 
pains  in  the  head  or  by  muscular  twitchings,  or  the  initial 
attack  may  be  characterised  by  unilateral  convulsions,  and  in 
these  cases  the  half  of  the  body  convulsed  corresponds  with 
that  which  is  subsequently  paralysed.  But  when  convulsions 
occur  after  paralysis  has  become  established,  it  usually  happens 
that  the  non-paralysed  side  is  the  one  which  is  affected  with 
clonic  spasms,  and  in  these  cases  there  is  probably  co-existing, 
but  unequal,  damage  to  both  hemispheres  of  the  brain. 

Some  of  the  patients  whose  hemiplegic  condition  is  ushered 
in  by  convulsions  speedily  die,  whilst  others  remain  liable  to 


532  FOCAL   DISEASES,  ACCORDING  TO 

a  recurrence  of  epileptiform  attacks  at  variable  intervals ;  in 
many  cases  no  subsequent  attack  occurs,  even  though  the 
patient  live  for  many  years.  Another  remarkable  peculiarity 
with  respect  to  cases  initiated  by  convulsions  is,  that  the 
period  of  stupor  or  partial  unconsciousness  may  be  prolonged 
for  three,  four,  five,  or  even  six  weeks,  and  yet  the  patient  may 
recover.  In  these  casesj  however,  the  patient  is  not  deeply 
comatose,  but  lies  in  a  somewhat  lethargic  condition,  with 
eyes  closed  or  only  half  open,  and  takes  no  notice  of  anything 
that  is  going  on  around  him.  A  patient,  on  the  other  hand, 
who  continues  deeply  comatose  for  forty-eight  hours  very  rarely 
recovers. 

(iii.)  Simple  Onset. — In  the  simple  mode  of  onset  the  patient 
may  suddenly  fall  owing  to  paralysis  of  an  inferior  extremity, 
but  the  fall  is  not  accompanied  by  any  loss  of  consciousness. 
The  patient  may  experience  no  pain,  but  usually  complains  of 
a  feeling  of  "  numbness "  in  the  paralysed  side  of  the  body. 
This  mode  of  invasion  is  very  frequent  in  the  slighter  forms  of 
hemiplegia. 

Temperature. — The  variations  of  the  temperature  of  the  body 
in  cases  of  apoplexy  have  been  studied  with  great  care  by 
Bourneville.  The  temperature  is  at  first  lowered  in  all  cases, 
sometimes  reaching  96'5°  F.,  and  in  the  fulminating  form  of  the 
disease  it  remains  low  until  death.  If  life  continue  for  ten  or 
twenty  hours  the  initial  sinking  gives  place  to  a  marked  eleva- 
tion of  temperature.  If  the  primary  depression  is  followed  by 
a  steady  and  continuous  rise  of  temperature  it  is  a  very  un- 
favourable sign,  and  in  these  cases  the  pyrexia  may  reach 
108°  F.  before  death.  In  the  more  favourable  cases  the  initial 
lowering  is  followed  by  a  stationary  period,  during  which  the 
temperature  varies  between  99°  F,  and  100-5°  F,  and  continues 
to  oscillate  rather  irregularly  for  from  two  to  four  days.  If  the 
case  be  going  to  terminate  in  recovery,  and  supposing  there  be 
no  inflammatory  complications  of  other  organs,  the  temperature 
gradually  falls  to  the  normal  standard,  and  there  remains. 
When,  however,  the  case  is  to  terminate  fatally  in  the  course 
of  a  day  or  two  more,  the  stationary  period  is  followed  by  a 
rapid  and  continuous  rise  of  temperature,  which  is  a  not  less 
unfavourable  sign  than  when  the  same  occurs  after  the  period 
of  initial  lowering. 


.       THE   NATURE   OF   THE   LESION.  533 

Conjugated  deviation  of  the  eyes,  with  rotation  of  the 
head  away  from  the  paralysed  side  and  towards  the  hemi- 
sphere which  is  the  seat  of  disease,  usually  occurs  as  a  tem- 
porary symptom  in  all  cases  of  severe  cerebral  hasmorrhage 
(§  90).  The  eyes  are  usually  fixed,  but  occasionally  exhibit 
slight  nystagmus.  When  the  disease  is  situated  in  the  posterior 
half  of  the  pons  the  rotation  is  directed  towards  the  paralysed 
side  (Provost,  Grasset).  The  rotation  may  completely  disappear 
when  the  patient  falls  asleep. 

3.  Permanent  Sym^ptoms. — The  permanent  symptoms  caused 
by  cerebral  haemorrhage  consist  of  paral3^sis  of  voluntary  motion, 
generally  limited  to  one  side  of  the  body  (hemiplegia)  ;  various 
tonic  or  clonic  spasmodic  affections,  also  generally  limited  to  one 
side  of  the  body  (hemispasm) ;  and  unilateral  sensory  disturb- 
ances, including  affections  of  the  special  senses  (hemiantesthesia). 
As  these  affections  are  not,  however,  peculiar  to  heemorrhage, 
we  reserve  consideration  of  them  for  the  present. 

§  721.  Disturbances  of  the  Mental  Functions. — The  majority 
of  those  who  have  been  attacked  with  cerebral  heemorrhage  do 
not  regain  their  full  mental  vigour.  Memory  usually  fails,  more 
especially  for  recent  events.  In  the  daily  affairs  of  life  the 
judgment  of  the  patients  may  not  appear  to  have  suffered,  but 
they  are  unequal  to  any  unusual  intellectual  effort;  and  at 
times  the  intellect  may  progressively  decline,  reducing  the 
patient  to  a  state  of  childishness  or  pronounced  dementia.  At 
other  times  they  become  peevish,  whimsical,  irritable,  or 
give  way  to  outbursts  of  passion.  The  mental  affections  con- 
nected with  disturbance  of  speech  (aphasia)  will  be  hereafter 
considered. 

Trophic  and  Vaso-motor  Disturbances. — Immediately  after 
an  attack  the  paralysed  limbs  of  a  hemiplegic  patient  are 
frequently  redder  and  warmer  than  the  corresponding  healthy 
limbs.  The  difference  in  temperature  may  vary  from  a  fraction 
of  a  degree  to  as  much  as  two  degrees.  These  symptoms  are 
no  doubt  due  to  paralysis  of  the  sympathetic.  About  twenty- 
four  hours  after  the  beginning  of  an  attack  the  paralysed  limbs 
may  become  swelled  owing  to  a  certain  amount  of  subcutaoeous 
oedema.     The  temperature   of  the  paralysed  limbs  gradually 


534  FOCAL  DISEASES,  ACCORDING  TO 

decreases,  and  is  eventually  lower  than  that  of  the  sound  side. 
When  no  oedema  exists  the  skin  may  be  dry  and  scaly. 

Acute  Bed-sore. — This  is  an  acute  process  of  sloughing,  which  occasionally 
occurs  over  the  centre  of  the  gluteal  region  on  the  paralysed  side,  after 
cerebral  haemorrhage  or  softening.  The  affection  has  already  been 
sufficiently  described  (§  114). 

Congestions  and  Hcemorrhages. — Congestions  and  actual  hfemorrhages 
into  the  substance  of  the  lungs,  extravasations  in  or  beneath  the  pleura, 
endocardium,  and  the  mucous  membrane  of  the  stomach,  as  well  as 
into  the  substance  of  the  supra-renal  capsules  and  kidneys,  frequently 
accompany  cerebral  haemorrhage.  SchifF  and  Brown-Se'quard  produced 
experimentally  hyperaemia,  or  haemorrhage  of  the  pleiu-a  and  lungs,  by 
certain  lesions  of  the  pons,  middle  cerebellar  peduncles,  and  the  optic 
thalami  and  corpora  striata.  These  hyperaemic  conditions  and  haemorrhages, 
whether  in  the  lower  animals  or  in  man,  are  sometimes  confined  to  the 
paralysed  side  of  the  body.  The  diminution  of  the  contractile  power 
of  the  walls  of  the  arterioles  on  the  paralysed  side  often  gives  rise  to  a 
perceptible  difference  between  the  radial  pulses  of  the  two  sides. 

Inflammcdion  of  the  Joints. — Some  of  the  joints  of  the  paralysed  side 
of  the  body  may  become  the  subjects  of  a  subacute  inflammation,  which 
usually  begins  from  the  third  to  the  sixth  week  after  the  hemiplegia, 
although  sometimes  the  joints  inflame  at  a  still  later  period  after  the 
beginning  of  the  attack,  and  occasionally  the  affection  shows  itself  as 
early  as  the  fifteenth  day.  There  are  the  two  varieties  of  this  articular 
inflammation,  the  one  acute  and  the  other  chronic.  In  the  fii'st  variety 
the  joint  becomes  red,  hot,  swollen,  and,  after  death,  acute  sj-novitis,  fre- 
quently with  considerable  exudation,  is  discovered.  This  form  almost 
exclusively  attacks  the  larger  joints.  A  chronic  joint  aflTection  has  been 
described  by  Hitzig  which  seems  to  be  pecuHar  to  the  shoulder.  The 
joint  is  almost  immovable,  painful  on  pressure,  and,  owing  to  paralysis  of 
the  muscles,  the  humerus  semi-dislocated. 

Changes  in  Nerve  Trunks. — Cornil  has  shown  that  in  a  certain  number 
of  cases  there  is  a  sub-inflammatory  hypertrophy  of  the  nerves  or  of  their 
sheaths,  and  in  such  cases  there  is  pain  on  pressure  of  the  paralysed 
limb,  especially  marked  along  tlie  course  of  the  principal  nerve-trunks. 
At  other  times  the  whole  paralysed  side  may  be  generally  tender,  without 
any  special  limitation  of  the  tenderness  to  the  joints  and  large  nerves. 

Muscular  Atrophy. — In  some  rare  cases  an  early  and  rapid  wasting 
takes  place  in  the  muscles  of  one  or  both  hmbs  a  few  weeks  after  the 
onset  of  the  paralysis,  but  in  these  cases  there  is  reason  to  beheve  that 
the  fibres  of  the  pyramidal  tract  have  undergone  secondary  degeneration, 
and  that  the  motor  cells  of  tbe  anterior  horns  of  the  cord  have  become 
implicated  in  the  process. 

Arrest  or  Retardation  of  Growth  in  Paralysed  Limbs. — When  hemi- 
plegia occurs  in  childhood,  the  a.rm  and  leg,  or  the  arm  only,  on  the  para- 


THE   NATURE   OF   THE  LESION.  535 

lysed  side  grow  more  slowly  than  on  the  sound  side,  so  that  as  growth 
advances  the  limbs  of  the  paralysed  remain  permanently  smaller  than 
those  of  the  opposite  side.  The  arm  is  more  frequently  affected  than  the 
leg,  and  there  is  always  a  certain  amount  of  muscular  rigidity  of  the 
affected  extremity. 

Skin,  Hair,  and  Nails. — The  skin  of  the  paralysed  side  sometimes 
undergoes  trophic  changes,  which  involve  the  cutis  and  subcutaneous 
tissue,  so  that  a  fold  pinched  up  by  the  fingers  feels  thicker  than  normal. 
The  hair  grows  better  on  the  afifected  side,  and  the  nails  become  yellowish, 
marked  with  ridges,  brittle,  and  curved. 

§  722.  Morbid  Anatomy. — Morbid  anatomists  usually  divide 
cerebral  haemorrhage  into  two  varieties,  named  respectively 
pwnctiform  and  massive  hsemorrhages, 

Punctiform,  hmmorrhages  occur  in  the  form  of  a  number 
of  minute  points  of  the  size  of  a  pin's  head,  or  even  smaller. 
They  result  from  rupture  of  capillary  vessels,  and  are  invariably 
multiple.  Capillary  haemorrhages  are  observed  in  the  tissues 
surrounding  massive  haemorrhages,  or  in  parts  which  are  the 
seat  of  softening,  and  they  are  met  with  in  considerable  numbers 
in  the  cortex  of  the  brain  in  consequence  of  thrombosis  of  the 
venous  sinuses.  At  other  times  extravasations  of  blood  are 
found  in  the  lymph  sheaths  of  the  vessels,  and  they  must  then 
be  regarded  as  minor  degrees  of  the  massive  haemorrhages. 

Massive  hcemorrhages  may  be  of  various  sizes,  being 
sometimes  as  small  as  a  pea,  at  other  times  large  enough 
to  destroy  almost  an  entire  hemisphere.  The  hemorrhage 
may  either  separate  the  nerve  fibres  of  the  white  substance  or 
rupture  them,  the  latter  event  being  by  far  the  more  frequent. 
When  the  nerve  fibres  are  pushed  aside  by  the  haemorrhage 
without  rupture  the  form  assumed  by  the  clot  will  be  deter- 
mined by  the  direction  of  the  fibres,  but  when  the  fibres  are 
ruptured  the  clot  is  round  or  oval.  In  the  cortex  the  form 
assumed  by  the  haemorrhage  is  largely  determined  by  the  dis- 
position of  the  convolutions  and  membranes,  so  the  effusion 
usually  spreads  out  laterally  and  assumes  an  irregular  form. 
Massive  haemorrhages  are,  as  a  rule,  single,  although  several 
foci  may  occasionally  be  observed,  and  it  is  not  unusual  to  find 
traces  of  many  extravasations  of  various  ages  in  the  same  brain. 

Haemorrhagic  foci  may  occupy  any  part  of  the  brain,  but 


536  FOCAL   DISEASES,   ACCOEDING  TO 

they  are  much  more  frequent  in  certain  parts.  The  favourite 
seats  are  the  caudate  and  lenticular  nuclei,  and  the  optic 
thai  ami. 

Recent  Focus. — In  the  recent  condition  the  apoplectic  focus 
forms  a  dark  red  clot,  which  is  soft  and  uniform  in  character 
throughout.  It  is  frequently  mixed  with  the  debris  of  the 
substance  of  the  brain.  The  internal  surface  of  the  cavity  is 
irregular  and  consists  of  torn  shreds  of  cerebral  tissue.  This  is 
surrounded  by  a  zone  of  variable  thickness,  averaging  a  few 
lines  in  depth  and  gradually  merging  into  the  healthy  tissues, 
composed  of  softened  tissue  saturated  with  blood  serum,  and 
frequently  the  seat  of  punctiform  haemorrhages.  If  the  nerve 
fibres  have  been  simply  separated  from  one  another  without 
rupture,  then  the  detritus  of  cerebral  tissue  in  the  internal 
surface  of  the  walls  of  the  cavity  is  absent,  and  the  softening 
and  punctiform  hsemorrhages  of  the  surrounding  tissues  are 
much  less  marked.  If  the  clot  be  floated  out  under  water,  it  is 
sometimes  possible  to  detect  the  miliary  aneurism  from  which 
the  primary  extravasation  took  place. 

Period  of  Ahsorj)tion  and  Repair. — If  the  hsemorrhage 
does  not  end  fatally  after  a  few  hours  structural  changes  take 
place,  both  in  the  clot  and  surrounding  tissues,  which  lead 
to  the  absorption  of  the  former  and  to  a  certain  amount 
of  repair  in  the  latter.  The  blood-clot  after  coagulation 
parts  with  its  serum,  and  the  injured  tissues  surrounding  the 
clot  become  softened,  partly  by  imbibition  of  serum,  but 
chiefly  owing  to  a  retrograde  fatty  metamorphosis  of  the 
torn  fragments  of  brain  tissue.  The  softened  tissues  become 
mixed  with  the  clot  so  as  to  form  a  dark,  chocolate-coloured 
mass,  of  the  consistence  of  gruel,  the  more  fluid  constituents 
of  which  are  soon  absorbed.  The  hsematine  is  dissolved,  and 
soaks  into  the  tissue  round  the  clot  to  a  considerable  distance, 
until  it  is  absorbed.  As  a  result  of  this  process  the  pulpy  material 
filling  the  cavity  passes  from  its  first  dark  red  to  a  brighter  red, 
and  finally  to  a  saffron  colour.  A  reparative  process  now  begins, 
by  means  of  which  the  hs3morrhagic  focus  is  converted  into  a 
cyst.  The  first  step  in  the  reparative  process  is  the  formation  of 
a  fibrinous  capsule  round  the  entire  periphery  of  the  clot.  It  is 
at  first  a  line  or  more  in  thickness,  soft  as  jelly,  and  of  a  trans- 


THE   NATURE   OF   THE   LESION.  537 

lucent  yellowish  tint.  At  a  later  period  this  capsule  becomes 
converted  into  a  much  thinner  but  stronger  layer  of  fibrillar 
connective  tissue,  which  permanently  shuts  off  the  apoplectic 
deposit  from  the  surroundiog  substance  of  the  brain.  The 
fluid  contained  in  the  cyst  is  at  first  turbid,  but  after  a  time 
becomes  transparent  and  limpid.  These  cysts,  however,  contain 
not  fluid  merely  but  also  a  loose  spongy  connective  tissue,  which 
is  suspended  iu  the  fluid  like  a  film.  But  the  reparative  pro- 
cess does  not  always  end  here;  the  whole  of  the  fluid  may 
become  gradually  absorbed,  and  the  opposite  walls  of  the 
cavity  may  ultimately  come  into  contact,  and  adhere  to  one 
another  by  a  connective  tissue,  which  usually  contains  a  consider- 
able amount  of  pigment.  This  constitutes  the  hsemorrhagic  or 
apoplectic  cicatrix,  which  consists  merely  of  a  thin  strip  of  con- 
nective tissue.  Superficial  foci  in  the  cortex  pass  through  similar 
phases,  and  after  cicatrisation  they  appear  as  yellow  indurated 
spots  which  have  been  taken  for  vestiges  of  encephalitis. 

Duration  of  the  Reparative  Process. — The  clot  is  soft  and 
homogeneous  during  the  first  three  or  four  days.  At  this  time 
the  process  of  softening  and  separation  of  the  internal  surface 
of  the  cavity,  and  the  absorption  of  the  fluid  contents,  reach 
their  maximum  activity  at  the  eleventh  or  twelfth  day.  The 
reparative  process  which  leads  to  the  formation  of  the  capsule 
begins  usually  from  the  seventh  to  the  ninth,  the  cyst  is  com- 
plete about  the  twentieth,  and  the  lining  membrane  is  organised 
from  the  thirtieth  to  the  fortieth  day. 

Circumstances  which  prevent  the  Reparative  Process. — 
Various  circumstances  delay  or  entirely  prevent  the  reparative 
process.  The  principal  of  these  are,  a  too  extensive  sero-san- 
guineous  infiltration  of  the  surrounding  tissues  followed  by  a 
co-extensive  area  of  softening,  an  excess  of  the  irritative  pro- 
cess necessary  to  repair,  which  gives  rise  to  secondary  encepha- 
litis, a  fresh  hasmorrhage  and  dropsy  of  the  cyst,  leading  to 
distention  and  consequent  pressure  on  the  surrounding  tissues. 
Repair  of  injury  to  the  brain  from  haemorrhage  may  be  pre- 
vented, like  repair  of  injuries  of  every  part  of  the  body,  by 
the  general  state  of  the  health  in  various  conditions  of  debility. 

§  723.  Prognosis. — The  prognosis  in  any  given  case  depends 


538  FOCAL   DISEASES,  ACCORDING  TO 

upon  the  opinion  formed  of  the  extent  and  situation  of 
the  lesion  taken  in  conjunction  with  the  age  and  previous 
state  of  health  of  the  patient.  Death  not  unfrequently  takes 
place  during  the  apoplectic  condition.  If  the  patient  cannot  be 
roused  at  all,  if  there  be  no  signs  of  reflex  activity  when  the 
conjunctiva  is  touched,  while  there  is  involuntary  passage  of 
fseces  and  urine,  and  well-marked  stertor,  the  patient  may  die 
rapidly  within  a  few  hours,  or  even  a  few  minutes ;  and  the 
persistence  of  a  slighter  degree  of  these  symptoms  without 
abatement  is  a  sign  of  great  gravity.  Laboured  respiration  and 
quickness  with  marked  irregularity  of  the  pulse,  are  also  un- 
favourable signs.  A  marked  and  persistent  depression  of  the  tem- 
perature is  regarded  by  Charcot  as  an  almost  certainly  fatal  sign. 
If  the  patient  has  recovered  from  the  apoplectic  condition,  then 
the  prognosis  will  greatly  depend  upon  the  age  and  general 
condition.  Granular  disease  of  the  kidneys,  a  general  state 
of  malnutrition,  or  evidences  of  senile  degeneration  of  the 
arterial  system,  will  render  the  ultimate  prognosis  grave 
in  cases  where  the  extent  and  situation  of  the  hsemorrhage 
itself  would  cause  no  danger  to  life.  A  sudden  rise  of  tempera- 
ture in  cases  of  cerebral  haemorrhage  is  a  very  grave  indication, 
unless  some  inflammatory  complication  be  present  to  account 
for  it.  A  sudden  depression  of  temperature,  with  increase  or 
renewal  of  a  pre-existing  comatose  condition,  indicating  as  it 
does  the  occurrence  of  a  fresh  haemorrhage,  is  also  of  serious 
import. 

Acute  sloughing  of  the  buttock  on  the  paralysed  side,  cotn- 
mencing  within  a  few  days  after  the  onset  of  the  apoplectic 
attack  is,  according  to  M.  Charcot,  of  fatal  significance.  Decided 
difiiculty  of  deglutition  and  articulation  is  also  a  serious 
symptom,  being  indicative  of  marked  interference  with  the 
functional  activity  of  the  medulla  and  pons.  When  the  patient 
has  outlived  the  apoplectic  attack,  the  period  of  reactive  inflam- 
mation brings  new  dangers,  when  death  may  result. 

When  the  inflammatory  period  is  passed  there  is  compara- 
tively little  reason  to  expect  a  fatal  result  from  the  brain  lesion 
itself  or  from  its  more  immediate  complications.  In  middle- 
aged  and  old  people,  however,  there  is  a  constant  danger  of  a 
recurrence  of  the  haemorrhage.     The  dangers  of  the  apoplectic 


THE   NATURE   OF   THE   LESION.  589 

attack  having  been  surmounted,  the  point  which  has  to  be 
determined  is  the  degree  of  improvement  likely  to  take  place 
in  the  patient's  mental  faculties,  in  his  power  of  articulation 
and  speaking,  and  as  regards  the  probability  of  restoration  of 
motor  power  to  his  paralysed  limbs. 

In  the  majority  of  instances  when  the  first  loss  of  conscious- 
ness has  passed  away,  the  patient  is  left  free  from  any  very 
decided  mental  defect,  except  a  certain  amount  of  mental  weak- 
ness and  a  tendency  to  emotional  displays.  In  rare  cases  the 
hemiplegic  attack  is  followed  by  a  chronic  maniacal  condition, 
which  may  pass  into  a  state  of  complete  dementia.  This 
condition  is  apt  to  follow  limited  cortical  haemorrhage  of  the 
occipital  lobes,  especially  in  elderly  people,  but  the  hgemorrhage 
may  itself  be  only  an  effect  of  previously-existing  degenerative 
changes. 

Large  lesions  occurring  in  infancy  or  at  the  time  of  birth, 
either  in  the  substance  or  on  the  surface  of  the  brain,  often 
induce  a  semi -idiotic  condition. 

§  724,  Treatment. — The  aims  of  treatment  are  (1)  to  avert  a 
threatened  attack;  (2)  to  treat  the  apoplectic  condition;  (3)  to 
allay  excitement  during  the  stage  of  inflammatory  reaction  ;  and 
(4)  to  restore  power  to  the  paralysed  limbs,  and  to  improve  the 
other  morbid  conditions  which  accompany  the  hemiplegic  state, 

(1)  Prophylaxis. — In  devising  measures  to  prevent  a  threa- 
tened attack,  each  case  must  be  made  the  subject  of  special 
study;  and  much  depends  for  the  success  of  these  on  the  age, 
general  state  of  health,  and  hereditary  tendencies  of  the  patient. 
Bodily  and  mental  rest  are  absolutely  necessary.  The  patient 
ought  to  be  kept  cool,  with  his  head  and  shoulders  well  raised. 
If  the  patient  be  beyond  middle  age,  with  signs  of  arterial 
degeneration  and  a  weak  intermittent  action  of  the  heart, 
stimulants,  cardiac  tonics,  and  the  frequent  administration  of 
easily-assimilated  fluid  nutriment  is  necessary.  In  the  presence 
of  a  moderate  amount  of  granular  disease  of  the  kidneys  with 
cardiac  hypertrophy  and  high  arterial  tension,  saline  purgatives 
are  indicated. 

(2)  Within  the  last  few  years  our  treatment  of  the  apoplectic 
condition  has  undergone  a  great  change.   Bleeding  was  regarded 


540  FOCAL   DISEASES,   ACCORDING  TO 

as  the  great  remedy  for  the  apoplectic  condition  from  the  time 
of  Hippocrates  down  to  within  a  few  years  ago,  when  the 
teachings  of  Todd  and  Trousseau  produced  a  reaction  in  the 
opposite  direction.  When,  however,  haemorrhage  takes  place 
in  a  case  associated  with  high  arterial  tension,  a  small  bleeding 
may,  by  lowering  the  blood  pressure  and  thus  diminishing  the 
intracranial  pressure,  avert  for  a  time  threatening  symptoms. 
If  the  heart  be  feeble,  with  compressible  pulse,  then  bleeding 
is  entirely  inadmissible. 

If  there  be  much  heat  of  the  head,  with  violent  throbbing 
of  vessels,  pounded  ice  in  a  bladder  or  india-rubber  bag,  or 
evaporating  lotions  should  be  applied  while  the  head  and 
shoulders  are  raised,  and  everything  about  the  neck  loosened. 
In  the  present  day  it  is  superfluous  to  condemn  the  barbarous 
practice  of  applying  mustard  plasters  to  the  calves  of  the  legs. 

A  stimulating  treatment  is  required  when  the  heart's  action 
is  feeble  and  the  respiratory  centre  is  threatened.  In  such  a 
case  the  patient's  face  is  cold  and  clammy,  the  pulse  feeble, 
and  the  respiration  hesitating  and  intermittent,  or  it  may  be 
assuming  the  Cheyne-Stokes  character. 

If  the  disease  be  characterised  by  recurring  epileptiform 
attacks,  bromide  of  potassium  may  be  administered,  and  if  there 
be  a  restless  condition,  with  more  or  less  of  delirious  wandering, 
the  same  drug  or  bromide  of  camphor  may  be  useful.  If  the 
bowels  be  constipated,  an  enema  containing  castor  oil  or  castor 
oil  and  turpentine  may  be  administered,  or  two  drops  of  croton 
oil  may  be  given.  The  state  of  the  bladder  must  also  be 
attended  to,  and  a  catheter  used  if  necessary.  In  many  cases  no 
drugs  are  required  during  the  apoplectic  stage,  and  purgatives 
should  not  be  resorted  to  on  all  occasions  as  a  routine  treatment 
irrespective  of  the  nature  of  the  case. 

(3)  If  the  patient  survive  the  first  shock  of  the  apoplectic 
attack  the  less  we  interfere  during  the  first  few  days  the 
better.  He  must  be  kept  as  quiet  as  possible  both  in  body 
and  mind,  and  his  diet  and  secretions  must  be  carefully 
regulated.  When  the  reactive  febrile  symptoms  appear  cold 
should  be  applied  to  the  head,  but  the  old  practice  of  bleeding 
at  this  stage  is  to  be  strongly  condemned.  If  headache  be  pre- 
sent along  with  persistent  wakefulness  or  delirium,  it  may  be 


THE  NATURE   OF   THE   LESION.  541 

necessary  to  administer  a  full  dose  of  bromide  of  potassium  or 
even  an  opiate  or  chloral.  During  this  time  great  care  must  be 
taken  to  prevent  bed-sores  on  the  paralysed  side,  by  paying 
constant  attention  to  the  state  of  the  bedding  and  securing  ex- 
treme cleanliness.  In  severe  cases  the  patient  should  be  placed 
on  a  water  bed  from  the  first  where  this  is  possible. 

(4)  The  most  efficient  means  of  promoting  the  improvement 
of  the  condition  of  the  paralysed  nerves  and  muscles  is  a 
thorough  attention  to  the  general  health  of  the  patient.  The 
treatment  which  it  will  be  necessary  to  adopt  will  depend  on 
the  age,  habits,  and  constitution  of  the  patient,  and  on  the  pre- 
sence or  absence  of  any  special  concomitant  disease.  The 
general  principles  of  treatment,  however,  are  to  take  care  that 
the  patient  has  easily-digestible  and  nutritious  food ;  that  all 
circumstances  which  might  cause  mental  excitement  are  avoided; 
and  that  the  patient  has  a  due  amount  of  repose  and  sleep.  In 
the  hemiplegias  of  elderly  people,  which  are  usually  associated 
with  miliary  aneurisms,  great  care  must  be  taken  that  the  cir- 
culation is  not  subjected  to  any  sudden  strain,  and  with  this 
object  it  is  necessary  to  take  care  that  the  bowels  do  not  become 
constipated,  lest  the  straining  at  stool  should  induce  another 
attack.  Iodide  of  potassium  is  often  beneficial.  The  patient 
should  also  take  open-air  exercise  in  a  chair  or  carriage  when- 
ever the  weather  is  suitable;  and  much  good  may  be  done 
at  a  later  period  of  the  disease  by  sponging  with  salt  water, 
either  tepid  or  cold,  or  even  by  shower  baths.  When  there  is 
advanced  degeneration  of  the  arteries  or  high  arterial  tension, 
great  caution  is  necessary  in  the  use  of  cold  sponging  and 
shower  baths,  since  the  sudden  impression  on  the  cutaneous 
surface  will  be  followed  by  contraction  of  the  arterioles  dis- 
tributed to  the  surface  of  the  body,  and  this  will  be  followed 
by  sudden  increase  of  the  arterial  tension,  and  consequent  risk 
of  the  rupture  of  another  vessel.  It  may  indeed  be  laid  down 
as  a  rule  that  hemiplegic  patients  should  only  use  baths  of 
moderate  temperature. 

These  general  measures  should  after  a  time  be  followed 
by  local  treatment  of  the  paralysed  limbs.  The  first  local 
measures  to  be  resorted  to  are  passive  movements  of  the 
paralysed    limbs,    and    friction    of   the    skin    by    means    of   a 


542  FOCAL   DISEASES,  ACCORDING  TO 

flesh  brush,  flannel,  or  the  palm  of  the  hand.  When  a 
paralysed  limb  is  painful,  gentle  rubbing  is  very  soothing  and 
grateful  to  the  patient.  The  patient  may  be  directed  to  make 
voluntary  efforts  to  move  the  limbs.  Electricity  is  one  of  the 
most  valuable  agents  we  possess  in  the  treatment  of  paralysed 
limbs.  Both  the  faradic  and  galvanic  currents  have  been 
employed,  but  the  latter  appears  to  be  the  more  generally 
useful.  The  constant  current  has  been  employed  in  three 
different  ways.  According  to  one  method  the  current  is  passed 
through  the  brain,  in  a  second  it  is  passed  through  the  cervical 
sympathetic,  while  in  a  third  it  is  directly  applied  to  the 
paralysed  limbs. 

The  practical  rules  which  must  be  observed  in  carrying  out 
the  treatment  are  the  following  : — 

(a)  This  metliod  of  treatment  should  not  be  adopted  in  the  early  stage 
of  hemiplegia,  as  injury  may  be  done  by  over-stimulation  of  the  brain. 

(6)  The  duration  of  each  application  through  the  brain  ought  to  be 
short,  not  exceeding  three  minutes. 

(c)  The  current  should  be  weak,  more  especially  in  the  case  of  elderly 
people — such,  for  instance,  as  that  derived  from  five  to  ten  or  at  most 
fifteen  Leclanch^'s  cells. 

(d)  The  electrodes  are  to  be  placed  on  the  mastoid  processes,  or  one 
on  the  mastoid  process  and  the  other  on  the  back  of  the  neck. 

(e)  The  electrodes  should  be  placed  in  position  when  the  index  is  at 
zero,  and  the  current  is  then  gradually  increased  and,  after  two  or  three 
minutes'  application,  gradually  diminished  before  the  electrodes  are  re- 
moved. Sudden  interruptions  and  raj)id  reversals  of  the  current  ought  to 
be  avoided. 

In  the  second  method  the  current  is  passed  through  the  cervical 
sympathetic.  In  this  method  the  electrodes  are  placed  over  the  coiu-se  of 
the  sympathetic  in  the  neck,  and  it  aj^pears  to  be  indifferent  whether  the 
anode  is  above  and  the  cathode  below  or  the  reverse.  The  currents  em- 
ployed may  be  stronger  than  when  the  brain  was  directly  acted  upon. 
From  fifteen  to  twenty-five  Leclanche's  cells  may  be  used. 

In  the  third  method  the  electrodes  are  used  along  the  course  of  the 
nerves,  the  negative  pole  being  placed  near  the  plexus  to  which  the  affected 
nerve  belongs,  or  over  the  corresponding  part  of  the  vertebral  column,  and 
the  positive  pole  over  the  trunks  of  the  nerves.  Some,  however,  recom- 
mend descending  instead  of  ascending  currents,  but  it  does  not  appear  to  be 
of  much  consequence  which  is  used.  The  cmTent  from  thirty  Leclanche's 
cells  may  be  used  for  about  eight  minutes,  and  in  order  to  increase  its 
stimulating  action  the  intensity  may  be  alternately  increased  and  dimi- 
nished, while  the  circuit  is  kept  closed.    Interruptions  and  reversal  of  the 


THE  NATURE   OF   THE   LESION.  543 

current  should  only  be  used  for  the  purposes  of  diagnosis.  This  mode  of 
applying  galvanism  to  the  paralysed  limbs  does  good  in  cases  of  clonic 
spasm  after  hemiplegia,  and  in  some  cases  of  "  late  rigidity ;"  but  when 
the  contracture  has  become  permanent,  so  that  it  does  not  intermit 
during  sleep,  it  is  hopeless  to  expect  any  benefit  from  treatment. 

Faradic  currents  have  been  employed  in  contractures  for  the 
purpose  of  acting,  not  on  the  contracted  muscles,  but  upon  their 
antagonists,  but  it  does  not  appear  that  much  benefit  has  ever 
resulted  from  this  treatment.  The  disturbances  of  sensibility 
on  the  paralysed  side  do  not  usually  require  any  special  treat- 
ment, since  the  measures  which  are  directed  to  mitigate  the 
motor  paralysis  exercise  a  favourable  influence  on  any  existing 
sensory  impairment.  If  there  be  hemiansesthesia,  metallo-thera- 
peutics,  as  employed  by  Charcot,  which  will  be  described  in  the 
section  on  hysterical  hemiansesthesia,  may  be  adopted,  but  our 
knowledge  of  this  subject  is  too  recent  and  too  imperfect  to 
enable  us  to  form  a  definite  opinion  of  its  merits. 

(b)  Meningeal  Rcemorrhage. 
Definition. — By  meningeal  hsemorrhage  is  here  meant  an 
extravasation  of  blood- between  the  membranes  or  on  the  surface 
of  the  brain. 

§  725.  Etiology. — The  most  frequent  causes  of  meningeal 
apoplexy  are  injuries  of  the  skull,  by  means  of  which  the  main 
meningeal  arteries,  the  sinuses,  or  the  vessels  of  the  pia  mater 
are  ruptured,  but  this  subject  belongs  to  surgery. 

Aneurisms  of  the  arteries  at  the  base  of  the  skull  may  by 
rupture  give  rise  to  meningeal  haemorrhage.  In  a  case  which 
came  under  my  observation,  a  large  meningeal  hemorrhage 
was  caused  by  rupture  of  an  aneurism,  about  the  size  of  a 
pea  on  the  left  Sylvian  artery,  about  an  inch  from  its  origin. 
Another  aneurism  unruptured,  symmetrical  with  it  in  size  and 
position,  was  found  on  the  right  Sylvian  artery.  Next 
to  the  middle  cerebral,  the  basilar  artery  is  most  frequently 
affected  with  aneurism.  Hseraorrhage  may  also  take  place  from 
the  veins,  and  large  meningeal  haemorrhage  may  result  from 
thrombosis  of  the  sinuses,  especially  the  superior  longitudinal 
sinus.  Blood  may  make  its  way  from  the  substance  of  the  brain 
into  the  meninges  through  rupture  of  the  cortex.     Meningeal 


544  FOCAL   DISEASES,  ACCORDING  TO 

hsemorrhage  may  result  in  the  course  of  infectious  diseases,  and 
chronic  dyscrasise,  and  frequently  occurs  in  the  course  of  the 
chronic  degeneration  of  the  cortex  of  the  brain,  which  underlies 
progressive  paralysis  of  the  insane. 

The  Qneningeal  apoplexy  of  new-born  children  is  caused  by 
certain  accidents  attending  childbirth. 

§  726.  Symptoms. — It  will  suffice  if  we  point  out  here  the 
differences  which  exist  between  the  symptoms  of  cerebral  and 
meningeal  hsemorrhages.  The  clinical  history  of  meningeal 
haemorrhages  of  traumatic  origin  is  usually  complicated  with 
other  cerebral  symptoms  directly  resulting  from  the  injury, 
such  as  concussion,  and  the  same  may  be  said  with  regard  to 
the  cases  Avhere  an  intracerebral  hgemorrhage  has  made  its 
way  to  the  surface  of  the  brain,  as  well  as  with  regard  to  the 
hgemorrhage  which  accompanies  general  paralysis.  Hsemorrhage 
caused  by  rupture  of  an  aneurism  forms  the  least  complicated 
class  of  cases. 

In  severe  cases  the  patient  becomes  suddenly  apoplectic 
without  any  warning,  or  with  only  slight  premonitory  symptoms, 
such  as  headache,  dizziness,  and  vomiting.  The  paralysis  is 
commonly  general,  affecting  all  four  extremities  uniformly,  and 
only  in  rare  cases  is  hemiplegia  met  with.  Epileptiform  convul- 
sions are  also  frequent  in  meningeal  hsemorrhage,  and  vomiting 
is  another  sign  often  observed.  These  cases  are  accompanied 
by  profound  coma,  and  death  results  in  a  few  hours,  or  at  most 
a  few  days. 

In  less  severe  cases  the  patient  may  partially  recover  after  a 
few  hours  from  the  apoplectic  state,  and  then  may  complain  of 
headache,  be  delirious  or  somnolent,  until  he  becomes  finally 
comatose. 

In  other  cases  the  patients  do  not  become  immediately  apop- 
lectic, but  complain  of  headache,  dizziness,  weakness  or  numb- 
ness of  the  extremities,  on  one  or  on  both  sides;  there  is  also 
more  or  less  stupor,  but  the  fatal  coma  may  not  supervene  for 
a  long  time.  In  these  cases  the  haemorrhage  appears  to  be 
small  at  first  and  gradually  to  increase. 

If  an  aneurism  of  considerable  size  have  existed  for  some 
time    before  the    occurrence   of  hsemorrhage,    the   apoplectic 


THE   NATURE   OF  THE   LESION.  545 

attack  may  be  preceded  by  some  of  the  symptoms  which  in- 
dicate the  existence  of  a  cerebral  tumour.  The  more  usual  of 
these  symptoms  are  headache,  double  optic  neuritis,  paralysis  of 
the  facial  nerve  in  aneurism  of  the  internal  carotid,  of  the  third 
nerve  in  aneurism  of  the  posterior  communicating  artery,  and 
vomiting,  epileptiform  convulsions,  and  disorders  of  deglutitioD, 
speech,  and  respiration  in  aneurism  of  the  basilar  artery. 

In  the  meningeal  haemorrhages  of  the  new-born,  the  children 
are  either  born  dead  or  in  a  condition  of  asphyxia,  and  die  soon 
afterwards.  If  respiration  be  established  the  infant  remains 
weak,  somnolent,  or  comatose,  and  dies  after  a  few  days  from 
convulsions.  Sometimes  the  children  are  weak  and  somnolent 
at  birth,  and  remain  in  this  condition  from  one  to  three  weeks, 
when  vomiting,  dyspnoea,  convulsions,  and  coma  supervene  and 
soon  prove  fatal. 

§  727.  Morbid  Anatomy. — The  blood  may  make  its  way 
into  the  arachnoid  space  in  consequence  of  injury  to  the  dura 
mater,  or  from  the  vessels  of  the  pia  mater,  or  from  the  cerebral 
vessels  and  subsequent  rupture  of  the  pia  mater.  When  the 
extravasation  is  large  the  haemorrhage  spreads  extensively 
through  the  arachnoid  space,  so  that  an  entire  hemisphere, 
or  exceptionally  the  surfaces  of  both  hemispheres,  may  be 
covered  with  a  thick  layer  of  blood.  When  a  large  collection 
of  blood  has  formed  at  the  base  and  around  the  pons  varolii,  it 
may  make  its  way  into  the  ventricles  through  the  great  trans- 
verse fissure,  and  pass  down  through  the  aqueduct  of  Sylvius  to 
the  fourth  ventricle.  The  quantity  of  the  effused  blood  may 
vary  from  a  few  drops  to  half  a  litre  or  more.  The  pigmented 
spots  sometimes  found  on  the  meninges  and  surface  of  the 
brain  seems  to  indicate  that  small  meningeal  haemorrhages  may 
be  absorbed,  but  large  haemorrhages  invariably  prove  fatal. 

The  appearances  presented  by  the  brain  vary  greatly,  accord- 
ing to  the  amount  and  seat  of  the  haemorrhage  and  the  time  at 
which  death  takes  place.  Haemorrhage  from  the  dura  mater,  if 
large,  compresses  without  rupturing  the  brain.  In  such  a  case 
the  gyri  are  found  flattened  and  the  substance  of  the  brain  pale. 
Haemorrhage  from  rupture  of  the  vessels  of  the  pia  mater 
or  of  the  brain  itself,  and  especially  rupture  of  an  aneurism 
JJ 


54!6  FOCAL   DISExVSES. 

of  the  larger  sized  arteries  at  the  base  of  the  brain,  may  cause 
considerable  destruction  of  cerebral  tissue. 

§  728.  The  prognosis  is  more  unfavourable  in  meningeal 
than  intra-cerebral  haemorrhage,  inasmuch  as  it  is  apt  to  be 
more  copious,  but  the  treatment  of  the  two  affections  is  similar. 
Trephining  may  possibly  be  of  use  in  some  cases  of  meningeal 
haemorrhage. 


547 


TEl 


CHAPTER  V 


(I.)     GENERAL    CONSIDERATION     OF     FOCAL    DISEASES, 
ACCORDING    TO    THE    NATURE    OF     THE    LESION 

(Continued). 


3.  INTRACRANIAL   TUMOURS. 

§  729.  Definition. — Intracranial  tumours  consist  of  circum- 
scribed pathological  growths  situated  within  the  cavity  of  the 
skull. 

§  730,  Etiology. — Tumours  of  the  brain  arise  from  similar 
causes  to  those  which  give  origin  to  tumours  in  other  localities. 
For  the  sake  of  convenience,  cerebral  tumours  may  be  divided 
into  {a)  New  formations  ;  (6)  Vascular  tumours ;  (c)  Parasites. 
Hereditary  predisposition  plays  an  important  part  in  the  pro- 
duction of  new  formations.  Cancerous  and  tubercular  tumours 
and  syphilitic  gummata  depend  upon  a  general  constitutional 
taint,  and  it  is  also  probable  that  glioma,  sarcoma,  and  other 
tumours  are  more  liable  to  arise  in  some  families  than  in  others. 
Cancer  is  one  of  the  most  common  tumours  of  the  brain,  and 
is  generally  primary.  When  secondary  it  often  follows  cancer 
of  the  orbit.  It  is  a  disease  of  adult  and  advanced  age,  the 
largest  number  of  cases  being  found  between  the  ages  of  thirty 
and  sixty  years.  Tubercle  on  the  other  hand  is  rarely  primary, 
but  is  generally  associated  with  tubercle  of  the  lungs  or  cheesy 
glands ;  it  is  essentially  a  disease  of  youth,  being  most  common 
between  the  ages  of  three  and  thirty  years.  It  is  probably 
the  most  frequent  of  all  cerebral  tumours.  Syphilitic  gummata 
may  be  met  with  at  every  period  of  life. 

Cerebral  tumours  are  more  frequent  in  men  than  in  women. 
Out  of  329  cases  of  cerebral  tumours  of  all  cases  collected  by 


548  FOCAL   DISEASES,   ACCORDING  TO 

Ladame  208  were  male,  95  female,  and  in  26  the  sex  was  not 
stated,  so  that,  according  to  this  computation,  the  proportion 
is  rather  more  than  two  to  one.  Injuries  of  the  skull  act  as 
exciting  causes  in  the  production  of  cerebral  tumours.  Several 
cases  have  come  under  my  own  observation  in  which  the  disease 
dated  from  a  blow  on  the  head,  and  the  tumour  in  these  cases 
frequently  grew  at  a  place  corresponding  to  the  seat  of  injury. 

Vascular  tumours  consist  of  aneurisms  of  the  cerebral 
arteries  and  erectile  tumours.  Aneurisms  are  observed  at  all 
ages,  but  they  are  more  common  between  the  ages  of  forty  and 
sixty  years,  when  the  vessels  begin  to  undergo  atheromatous 
degeneration  ;  the  causes  of  erectile  tumours  are  unknown. 

The  parasites  met  with  in  the  brain  are  the  cysticercus  and 
echinococcus. 

§  731.  Symptoms.— Headache  is  one  of  the  earliest  and  most 
striking  of  the  initial  symptoms  of  intracranial  tumours. 
Ladame  found  this  symptom  in  two-thirds  of  the  cases  collected 
by  him.  Headache  is  more  violent  in  intracranial  tumour  than 
in  any  other  disease  except  meningitis  and  the  uraemia  of 
chronic  Bright's  disease ;  it  consists  of  an  acute  lancinating  or 
severe  boring  pain,  which  may  continue  many  weeks  without 
intermission,  and  is  aggravated  by  impressions  of  light,  noises, 
and  all  movements  of  the  head.  The  pain  sometimes  occupies 
the  occipital  and  at  other  times  the  frontal  or  temporal  regions; 
but  its  seat  has  no  necessary  relation  to  the  situation  of  the 
tumour,  although  constant  occipital  pain  is  often  associated 
with  cerebellar  tumour.  Neuralgic  headache  from  irritation  of 
the  fifth  may  be  associated  with  the  more  profound  headache 
of  general  pressure.  Tenderness  on  percussing  the  skull  may 
sometimes  be  observed  at  a  point  corresponding  to  the  situation 
of  the  tumour  (Ferrier). 

Dizziness  is  a  frequent  initial  symptom,  and  it  may  be 
present  with  or  without  cephalalgia.  Paroxysms  of  head- 
ache and  dizziness  may  be  the  only  symptoms  present  for 
months,  and  the  patient  may  feel  well  in  other  respects. 
Dizziness  is  probably  caused  by  alterations  in  the  circulation 
of  the  brain  induced  by  the  growth  of  the  tumour;  but  the 
insecurity  on  assuming  the  erect  posture,  which  is  one  of  the 


\ 


THE  NATURE   OF   THE   LESION.  549 

main  elements  of  vertigo,  is  frequently  caused  by  pressure  on 
the  labyrinthine  fibres  of  the  auditory  nerve. 

Sensory  disturbances  are  generally  ushered  in  by  hyper - 
sesthesia  or  some  other  irritative  phenomena,  which  are  after  a 
time  followed  by  anaesthesia.  Wandering  pains,  formication, 
tingling,  and  numbness  alternate  with  one  another  before  there 
is  a  distinct  diminution  of  sensation,  and  these  symptoms  do 
not  entirely  cease  until  complete  anaesthesia  is  established. 
Ladame  found  cutaneous  ansesthesia  in  one-seventh  of  his 
cases. 

Neuralgia  of  the  trifacial  nerve  arises  from  a  variety  of 
causes,  but  when  all  the  three  divisions  of  the  nerve  are  simul- 
taneously affected  the  presence  of  intracranial  tumour  is  to  be 
suspected.  The  pain  occurs  in  paroxysms,  and  is  usually  asso- 
ciated with  numbness,  formication,  itching,  and  the  feeling  of 
the  part  being  swollen.  When  sensation  is  diminished  on  the 
painful  side  the  pressure  of  a  tumour  on  the  nerve  may  be 
suspected,  and  the  diagnosis  is  rendered  more  certain  if  dis- 
turbances of  other  cranial  nerves  are  present. 

Motor  disturbances  are  generally  ushered  in  by  phenomena 
of  irritation,  to  be  followed  by  paralysis.  The  irritative 
symptoms  are  cramps  of  various  parts  or  tremor  of  one  of  the 
extremities  or  of  half  the  body.  The  cramps  may  vary  from 
slight  spasmodic  twitches  of  the  muscles  of  the  face  or  of  other 
special  groups  of  muscles,  to  persistent  tonic,  clonic,  or  choreiform 
muscular  spasms  in  the  extremities ;  or  there  may  be  epilepti- 
form convulsions,  accompanied  by  unconsciousness.  After  a 
longer  or  shorter  duration  the  irritative  motor  symptoms  give 
place  to  paralysis,  which  creeps  on  gradually,  and  does  not 
become  complete  for  a  comparatively  long  period.  Hemiplegia 
is  the  more  frequent  form  of  paralysis,  being  present  in  a  third 
of  Ladame's  cases.  Permanent  contractions  of  the  paralysed 
extremities  occur  when  the  pyramidal  tract  is  pressed  upon  or 
otherwise  injured,  but  the  spastic  condition  of  the  limbs  is 
seldom  so  pronounced  in  intracranial  tumours  as  in  other  focal 
diseases  of  the  brain.  The  paralysed  muscles  atrophy  apparently 
simply  from  disuse,  and  retain  for  a  long  time  their  electric 
excitability. 

Affections  of  the  Special  Senses. — With  respect  to  the  affec- 


550  FOCAL   DISEASES,   ACCORDING  TO 

tions  of  the  special  senses,  those  of  sight  are  by  far  the  most 
important  Calmeil  found  amblyopia  in  two-fifths  of  his  cases, 
and  Ladame  found  amaurosis  in  one-fifth.  The  optic  disc  may 
present  the  appearance  known  as  "  choked  disc "  (Stauungs- 
papilla),  or  there  may  be  neuritis  (§  207).  The  former  is 
by  far  the  most  important  sign  of  cerebral  tumour,  as  it  is 
generally  present  whenever  there  is  increased  intracranial 
pressure  ;  and  although  this  condition  is  said  occasionally 
to  accompany  fluid  effusion,  yet  the  usual  cause  is  a  solid 
growth. 

It  is  of  the  utmost  importance  for  regional  diagnosis  to 
examine  carefully  for  contractions  of  the  field  of  vision,  and  for 
the  different  varieties  of  hemiopia.  Diplopia  is  also  a  frequent 
symptom  of  tumours  at  the  base  of  the  brain,  caused  by  an 
affection  at  the  origin  or  pressure  in  the  course  of  the  third, 
fourth,  or  sixth  cranial  nerves. 

The  pupils  vary;  they  may  occasionally  be  contracted  or 
unequal,  but  when  by  the  growth  of  the  tumour  the  intracranial 
pressure  becomes  great,  they  are  always  dilated  and  react  feebly 
to  light. 

The  sense  of  hearing  is  also  frequently  affected.  Calm6il 
found  some  disturbances  of  hearing  in  one-ninth  of  his  cases ; 
Ladame  says  that  the  sense  of  hearing  is  affected  only  one 
half  as  often  as  the  sense  of  vision.  The  auditory  disturbances 
usually  consist  of  dulness  of  hearing  and  rushing  noises,  but 
complete  deafness  is  sometimes  observed. 

The  injection  experiments  of  E.  Weber  have  shown  that 
there  is  a  communication  between  the  arachnoid  cavity  and  the 
labyrinth  by  means  of  the  aqueduct  of  the  cochlea,  and  con- 
sequently increased  intracranial  pressure  may  produce  an 
affection  of  the  auditory  apparatus  similar  to  that  which  occurs 
in  the  eyes  under  the  same  circumstances.  Alterations  of 
hearing  may  likewise  be  caused  by  pressure  on  the  trunk  of 
the  auditory  nerve  or  on  its  nuclei  of  origin  in  the  medulla  and 
pons.  Pressure  on  the  labyrinthine  fibres  of  the  auditory  nerve 
may  occasion  vertigo  and  disorders  of  motor  co-ordination  similar 
to  those  observed  in  Meniere's  disease. 

The  sense  of  smell  is  relatively  seldom  affected  in  cases  of 
tumour  of  the  brain.   The  number  mentioned  in  literature,  how- 


THE   NATUKE   OF   THE   LESION.  551 

ever,  is  not  a  true  criterion  of  the  real  number  affected,  since  the 
patient  is  very  apt  not  to  mention  the  loss  of  smell  unless  it 
be  entirely  lost,  and  the  physician  is  apt  not  to  make  any 
special  investigation  of  it.  Ladame  found  the  sense  of  smell 
distinctly  diminished  or  entirely  lost  in  ten  only  of  his  collected 
cases,  and  never  present  as  the  only  symptom. 

The  sense  of  taste  is  likewise  only  rarely  affected.  In 
Ladame's  collected  cases  mention  is  made  of  alterations  of  this 
function  only  seven  times,  once  the  affection  was  unilateral, 
and  the  sense  was  only  rarely  completely  lost.  There  are  good 
grounds,  however,  for  believing  that  if  taste  were  carefully 
tested  in  all  cases  of  cerebral  tumours,  alterations  would  be 
more  frequently  found. 

The  organic  functions  always  become  more  or  less  injured 
in  intracranial  tumour.  The  intense  cephalalgia  alone  prevents 
the  patient  from  sleeping,  and  the  continual  wakefulness  reacts 
on  the  general  health. 

Vomiting  is  frequently  associated  with  paroxysms  of  head- 
ache and  vertigo,  but  it  may  occur  independently  of  these. 
It  is  often  extremely  obstinate  and  may  continue  for  hours,  and 
when  it  recurs  frequently  the  general  nutrition  suffers  greatly. 
Constipation  is  usually  present,  but  in  some  cases  it  may  alter- 
nate with  diarrhoea.  Irregularity  of  the  heart's  action  and 
slowness  of  the  pulse  have  been  frequently  observed,  probably 
from  irritation  of  the  vagus.  Towards  the  end,  however,  the 
pulse  becomes  very  frequent. 

The  respiratory  function  is  not  often  disturbed,  but  the 
rhythm  may  be  quickened  by  irritation,  and  rendered  slower  by 
pressure,  of  the  brain.  Vierordt  and  Hegelmaier,  by  recording 
the  movements  of  the  superior  abdominal  region  of  rabbits  on 
the  drum  of  the  kymograph,  found  that  a  moderate  artificial 
pressure  on  the  brain  diminished  the  respirations  by  one-half, 
while  they  were  increased  in  number  by  a  stronger  pressure. 
With  moderate  pressure  the  inspirations  were  fewer  and  the 
expirations  longer. 

Polyphagia  is  an  occasional  symptom  of  cerebral  tumour, 
but  it  does  not  prevent  the  progressive  emaciation.  Rosenthal 
mentions  a  case  where  the  polyphagia  was  accompanied  with 
diabetes  mellitus. 


552  FOCAL  DISEASES,  ACCOEDING   TO 

Polyuria  and  saccharine  urine,  either  separately  or  com- 
bined, are  frequently  met  with.  In  these  cases  it  is  almost 
certain  that  there  must  be  irritation  of  the  floor  of  the  fourth 
ventricle,  but  the  irritation  need  not  be  direct.  Rosenthal  relates 
the  history  of  a  case  where  diabetes  was  caused  by  tumour  of 
the  pituitary  body,  and  I  have  seen  a  case  where  polyuria  was 
occasioned  by  a  tumour  situated  at  the  base  of  the  skull  over 
the  right  cavernous  sinus. 

Fever  is  not  a  usual  symptom,  but  it  is  sometimes  present 
during  an  attack  of  cerebritis,  these  complications  being  most 
frequently  observed  in  the  incipient  stage  of  tubercular  tumour. 

The  nutritive  disturbances  do  not  maintain  a  due  pro- 
portion to  the  gravity  of  the  cerebral  phenomena,  nor  does 
the  nature  of  the  tumour  appear  to  exert  a  marked  influence 
on  the  general  health.  Cases  have  been  observed  in  which 
cancer  of  the  brain  had  existed  for  some  months  without  pro- 
ducing a  perceptible  influence  on  the  nutrition  of  the  body, 
and  those  suffering  from  sarcoma  may  even  manifest  a  tendency 
to  obesity.  As  a  rule,  however,  the  subjects  of  tubercle  and 
cancer  sooner  or  later  exhibit  traces  of  cachexia.  Tumour  of 
the  brain  may  act  injuriously  on  nutrition  in  several  ways.  A 
state  of  great  marasmus  is  sometimes  induced  by  frequently 
recurring  vomiting,  while  at  other  times  the  vital  powers  of  the 
patient  become  exhausted  by  incessant  headache  and  sleep- 
lessness. 

Psychical  disturbances  are  frequently  observed  in  cerebral 
tumour,  but  the  statements  of  authors  differ  considerably  with 
respect  to  the  relative  frequency  of  the  symptom.  Andral  and 
Durand-Fardel  assert  that  mental  disturbances  occur  very  seldom, 
while  Calmeil  observed  psychical  disorders  in  one-half, Friedreich 
in  43  per  cent,  Lebert  in  one-third,  and  Ladame  in  rather  more 
than  a  third  of  their  cases.  Symptoms  of  mental  irritation  fre- 
quently precede  those  of  depression.  The  irritative  symptoms 
consist  of  mental  excitement  and  those  emotional  disturbances 
which  are  usually  known  as  hysterical,  ideas  of  grandeur,  with 
consequent  extravagance,  hallucinations,  delusions,  and  out- 
bursts of  passion  which  may  amount  to  maniacal  fury.  The 
symptoms  of  depression  consist  of  drowsiness,  apathy,  loss  of 
speech,  and  imbecility.     The  affections  of  speech  which  occur 


THE  NATURE   OF   THE   LESION.  553 

in  cerebral  tumour  are  variable  in  character.     Ladame  found 
affections  of  speech  in  45  of  his  collected  cases. 

Terminal  Phenomena. — As  the  tumour  grows  in  size  the 
brain  becomes  compressed  to  such  an  extent  that  its  functions 
become  gradually  abolished,  and  the  terminal  phenomena  of 
the  affection  are  ushered  in.  These  consist  of  extreme  emacia- 
tion, widely  spread  anaesthesia,  blindness  and  diminution  or  loss 
of  one  or  more  of  the  other  special  senses,  motor  paralysis 
often  implicating  all  the  extremities,  imbecility  and  deep  and 
enduring  coma. 

§  732,  Morbid  Anatomy. — The  morbid  growths  which  con- 
stitute intracranial  tumours  are  very  variable,  and,  regarded 
from  the  standpoint  of  pathological  anatomy,  have  little  or  no 
affinity  with  each  other,  but  are  conveniently  grouped  together 
for  practical  purposes  on  account  of  their  clinical  affinities. 
The  brain  is  surrounded  by  unyielding  osseous  walls,  and  the 
development  of  any  foreign  body  within  the  cranium  encroaches 
upon  the  space  occupied  by  it,  and  consequently  there  is  a 
close  similarity  in  the  symptoms  caused  by  intracranial  tumours 
however  different  in  nature. 

(a)   Varieties  of  hhtracranial  New  Formations. 

(1)  Glioma. — The  gliomata  form  tumours  which  vary  in  size  from  a 
cherry-stone  to  that  of  the  closed  fist ;  they  are  vascular,  of  a  white  or 
greyish-red  colour,  and  are  never  distinctly  circumscribed  from  the  tissues 
of  the  brain,  the  grey  matter  of  which  they  much  resemble  in  consistence 
and  colour.  The  hemispheres  of  the  brain  are  the  favourite  seats  of 
gliomata,  although  they  may  appear  in  any  part  of  the  brain  or  spinal 
cord.  Gliomata  are  composed  of  a  matrix,  which  varies  in  consistence, 
and  an  abundant  admixture  of  cells  and  nuclei.  The  cells  vary  in  shape 
and  size ;  they  are  sometimes  round  or  oval,  with  granular  contents  and 
one  or  two  nuclei ;  at  other  times  spindle-shaped  or  stellate,  and  provided 
with  fine  processes,  which  are  continuous  with  those  of  adjoining  cells. 
There  are  two  principal  varieties  of  gliomata,  the  hard  and  the  soft.  In 
the  hard  gliomata  the  cells  are  scanty,  and  usually  contain  several  nuclei. 
The  matrix  is  formed  of  fine  fibrillae,  which  are  more  or  less  parallel  to  one 
another,  and  can  sometimes  be  isolated  into  long  threads.  In  the  hardest 
forms  the  matrix  is  no  longer  formed  of  long,  separable  fibrillae,  but  of  a 
finely  reticular  substance,  which  can  only  be  separated  into  short  stiff 
fibres.  At  times  part  only  of  the  tumour  is  hard,  and  it  then  contains 
one  or  more  hard  kernels,  which  may  equal  in  density  fibro-cartilaginous 


554  .    FOCAL  DISEASES,  ACCORDING  TO 

tumours.  True  cartilaginous  structure  has,  however,  never  been  found 
in  these  tumours.  The  hard  ghomata  are  allied  in  general  characters  to 
the  fibromata,  and  intermediate  forms  are  met  with  which  are  termed 
fihro-cjlio''mata. 

In  ih.e  fibro-gliomata  the  matrix  consists  of  fibres  forming  thick  bundles, 
or  exhibiting  a  stratiform  arrangement  enclosing  here  and  there  nucleated 
cells. 

The  soft  gliomata  contain  more  cells  than  the  hard ;  the  cells  vary  con- 
siderably in  size  and  form,  but  are  generally  small  and  deficient  in  plasma. 
The  matrix  consists  of  a  fibrillary  network,  in  the  interstices  of  which  the 
cells  are  imbedded. 

Transitional  forms  between  the  soft  gliomata  and  other  tumours  are 
met  with.  When  the  number  and  size  of  the  cells  are  increased,  the 
tumours  are  allied  to  the  sarcomata,  and  are  therefore  called  glio-sarcomata ; 
and  when  the  matrix  assumes  a  mucoid  character,  the  tumoiu-  resembles 
the  myxomata.  The  gliomata  are  sometimes  richly  supplied  with  rela- 
tively large  blood-vessels,  constituting  what  Virchow  has  named  telean- 
gieotatic  glioma.  This  form  is  characterised  by  the  tendency  to  hsemorrhage, 
which  always  occurs  in  the  centre  of  the  tumour,  and  the  appearances 
presented  may  closely  resemble  simple  apoplexy.  Haemorrhagic  glioma 
usually  occurs  in  the  white  substance  of  the  hemisphere,  where  simple 
apoplexy  is  rarely  seen;  and  in  the  former,  even  when  the  tumour  is 
largely  destroyed  by  haemorrhage,  a  narrow  zone  surrounds  the  clot,  which 
is  sufficient  to  reveal  the  origin  of  the  mischief. 

Gliomata  grow  slowly,  and  the  tumour  generally  attains  a  large  size. 
That  these  tumours  undergo  retrogressive  changes  is  shown  by  the  fre- 
quent occurrence  of  fatty  degeneration  in  their  interior,  but  the  changes 
instead  of  leading  to  a  curative  process  are  much  more  likely  to  cause 
haemorrhage  as  soon  as  the  absorption  of  the  fatty  debris  lowers  and 
removes  the  pressure  on  the  vessels  in  the  interior  of  the  tumour.  By 
fatty  metamorphosis  and  softening  of  the  intercellular  substance  cavities 
form  which  may  be  distinguished  from  cysts  by  their  irregular  and  uneven 
walls.  In  the  vicinity  of  tumours  where  the  tissues  are  reddish  and 
softened,  fatty  grantiles,  cholesterine  crystals,  neurogha  nuclei,  and  frag- 
ments of  axis  cylinders  may  be  found. 

(2)  Hyperplasia  of  the  pineal  gland  is,  both  in  external  characters  and 
in  the  nature  of  its  elements,  very  similar  to  gUoma.  Virchow  says  that 
it  forms  a  solid,  greyish-red,  slightly  lobulated,  or  a  smooth  round  tumour, 
which  may  grow  to  the  size  of  a  walnut  or  even  larger.  On  section  it 
exhibits  the  well  known  grey,  moist,  vascular  tissue  of  the  pineal  gland, 
and  in  old  persons  a  large  number  of  the  sand-like  bodies  are  rarely 
absent.  Histologically,  the  cell  elements  are  somewhat  larger  and  firmer 
than  in  the  normal  gland.  These  tumours  produce  pressure  on  the  cor- 
pora quadrigemina  and  venae  magnae  Galeni,  and  that  on  the  latter  in  its 
turn  may  give  rise  to  secondary  hydrocephalus. 

(3)  Myxoma  is  rarer  in  the  brain  than  in  the  spinal  cord  and  peripheral 


I 


THE   NATURE   OF   THE   LESION.  555 

nerves.     It  takes  its   origin,   like  glioma,   from   an   overgrowth   of  the 
neuroglia,  and  extends  uniformly  in  all  directions  by  infiltration. 

(4)  Solitary  Tubercle,  which  is  by  far  the  most  common  tumour  of  the 
brain,  is  regarded  by  Rindfleisch  as  a  product  of  the  neuroglia,  and  as 
being  allied  to  \he  fibromata.  They  consist  of  hard  nodules,  varying  in  size 
from  a  pea  to  a  pigeon's  egg,  and  sometimes  even  larger,  of  grey,  yellow, 
or  yellowish- white  colour  and  globular  form.  On  section  the  interior  of 
the  nodule  is  yellowish  and  cheesy,  while  the  outer  cortex  is  of  a  reddish- 
grey  colour,  and  very  vascular.  The  thickness  of  the  cortical  layer  is 
inversely  proportional  to  the  size  of  the  tumour ;  in  a  tumom-  the  size  of  a 
hazel-nut  which  I  saw  lately  it  was  a  line  in  thickness,  and  in  another  of 
the  size  of  a  walnut  it  was  not  much  thicker  than  brown  paper.  The 
cortical  tissue  is  continuous  with  the  cheesy  nodule  on  the  one  side  and 
with  the  healthy  brain  matter  on  the  other.  These  tumours  are  met  with 
in  all  parts  of  the  brain  and  cord,  but  their  favourite  seat  is  the  cortical 
substance  of  the  cerebrum  and  cerebellum,  close  upon  the  cortico-medullary 
boundary.  This  tumour  is  frequently  multiple,  and  then  each  nodule  is 
usually  small ;  but  when  there  is  only  one  tumour  it  may  attain  a  con- 
siderable size.  Eindfleisch  distinguishes  a  tubercular  and  a  non- tubercular 
variety  of  the  solitary  cheesy  nodule. 

In  the  non-tubercular  variety  the  cortex  of  the  nodule  consists  of  a 
round-ceUed  embryonic  tissue,  in  which  nothing  peculiarly  tubercular 
can  be  detected.  The  layer  of  nervous  matter  surrounding  the  nodule  is 
also  infiltrated  with  corpuscular  elements,  and  thus  the  nodule  increases 
steadily  in  size.  Within  the  zone  of  proHferation  there  is  found  a  large 
development  of  fibres  between  the  corpuscular  elements  of  the  embryonic 
tissue,  rendering  it  dense,  while  the  cells  are  entirely  replaced  by  fibres  in 
the  centre. 

The  small  cheesy  nodules  are  usually  mvdtiple,  and  prove  on  minute 
examination  to  be  really  tuberculous.  The  grey  zone  of  proliferation 
which  surrounds  them  is  seen  with  the  naked  eye  to  consist  of  spherical 
nodules,  each  of  which  corresponds  in  shape  and  size  to  a  miliary  tubercle, 
while  the  interior  of  the  nodule  consists  of  tubercles  which  have  under- 
gone the  cheesy  transformation.  The  young  granules  are  continually  pro- 
duced at  the  circumference,  and  the  tumour  grows  by  the  constant  addition 
of  these.  When  the  nodule  has  attained  a  considerable  size,  the  process 
of  growth  stops,  and  a  fibrous  envelope  gradually  forms  round  the  mass, 
so  as  to  completely  isolate  it  from  the  surrounding  brain  tissue,  and  this 
condition  has  led  some  pathologists  to  believe  that  all  tubercles  occur 
in  an  encysted  condition  in  the  brain.  The  centre  of  the  nodule  some- 
times softens,  and  occasionally  the  whole  contents  of  an  encysted  tubercle 
may  undergo  this  change.  Very  rarely  the  tubercular  nodule  has  been 
fomid  to  have  undergone  a  process  of  cretification.  The  cortex  of  the 
tumour  consists  of  giant-cells,  each  being  surroimded  by  lymphoid  cells 
imbedded  in  a  fibrillated  reticulum. 

(5)  Carcinomata. — Cancer  of  the  brain  frequently  appears  as  fungus 


556  FOCAL  DISEASES,   ACCOEDING  TO 

haematodes  of  the  dura  mater.  When  it  originates  from  the  outer  surface  of 
the  dm'a  mater  it  forces  its  way  along  the  vessels  into  the  compact  tissue 
of  the  bones,  and  ultimately  perforates  them,  protruding  as  a  fungoid 
tumour,  and  pushing  the  scalp  before  it. 

Simple  cancer  of  the  brain  generally  grows  from  the  under  surface  of 
the  pia  mater,  and  even  such  tumours  as  appear  to  lie  free  in  the  substance 
of  the  brain  are  usually  connected  at  some  point  or  other  with  the  pia 
mater  lining  an  adjoining  sulcus.  Isolated  tmnours,  however,  do  exist, 
but  they  are  always  secondary.  Cancer  is  one  of  the  most  frequent  of  in- 
tracranial tumours.  It  is  generally  primary,  and,  as  a  rule,  remains  long 
isolated.  According  to  Lebert,  out  of  48  cases  45  were  primary,  and  of 
these  13  exhibited  simultaneously  carcinoma  of  other  organs.  Primary 
cancer  of  the  substance  of  the  brain  is  generally  single,  but  occasionally 
there  is  a  symmetrical  appearance  of  a  tumour  in  corresponding  parts 
on  each  side  of  the  brain.  Several  tumours  are  generally  found  in  the 
brain  in  the  secondary  form,  but  these  are  usually  small.  The  smallest 
cancerous  tumours  are  generally  found  embedded  in  the  hemispheres  of 
the  brain,  in  the  pons,  base  of  the  brain,  and  the  medulla  oblongata. 
Cancer  rarely  occurs  in  the  medulla  oblongata,  crm-a,  and  corpora  quad- 
rigemina,  relatively  more  frequent  in  the  optici  thalami,  corpora  striata, 
and  cerebellum. 

Cancerous  tumours  destroy  the  neighbouring  tissues  by  pressure  and 
infiltration.  They  are  surrounded  by  a  zone  of  softened  tissue  of  about 
a  line  in  breadth,  in  which  active  growth  proceeds.  The  microscope  dis- 
plays large  cells  rolled  into  nests,  and  crowded  together  in  a  matrix  of 
fibres  and  blood-vessels. 

Many  cancers,  especially  those  connected  with  bone,  exhibit  a  calcifi- 
cation of  their  stroma.  The  medullary  forms  undergo  a  cheesy  meta- 
morphosis, which  may  lead  to  their  being  mistaken  for  tubercle  of  the 
brain. 

(6)  Cholesteatoma,  or  pearl  cancer,  according  to  Rindfleisch,  "combines 
the  structure  of  an  epitheUoma  with  the  harmlessness  of  a  wart  or  fibroid 
thickening."  It  appears  to  be  derived  from  the  pia  mater,  and  is  usually 
situated  in  some  hollow  at  the  base  of  the  brain.  It  develops  from  iso- 
lated growths  of  the  size  of  a  mustard-seed,  which  blend  to  form  masses 
of  the  size  of  a  walnut.  The  tumour  is  enclosed  by  a  delicate,  indistinctly 
fibrous  capsule ;  it  has  an  irregular  form,  and  its  siu-face  presents  a  beau- 
tiful mother-of-pearl  lustre.  The  tumour  on  section  is  hard,  pearly,  non- 
vascular, and  composed  of  epidermic  cells  arranged  in  concentric  layers, 
which  have  undergone  partly  homy  and  partly  fatty  transformation. 
These  tumours  grow  very  slowly,  and  consequently  may  remain  for  a  long 
time  without  giving  rise  to  symptoms,  and  they  only  excite  irritation 
in  the  neighbouring  tissues  in  the  later  stages. 

(7)  Papilloma  of  the  pia  mater  is  occasionally  met  with ;  and  a  second 
variety  of  this  tumour,  in  which  there  is  an  abundant  production  of  mucus 
from  the  surface  of  the  papillse,  is  said  by  Eindfleisch  to  be  frequently 


THE   NATURE   OF   THE   LESION,  •         557 

mistaken  for  myxoma,  and  he  proposes  to  call  this  variety  papilloma 
myxomatodes. 

(8)  Syphilomata  are  usually  found  near  the  surface  of  the  brain  and 
develop  from  the  perivascular  sheaths.  They  may  reach  the  size  of  a 
walnut  or  even  a  hen's  egg.  In  their  interior  there  are  usually  several 
cheesy  patches,  while  the  circumference  is  made  up  of  soft  jelly-like  and 
very  vascular  tissue.  Syphilitic  gummata  are  made  up  of  highly  cellular 
embryonic  tissue,  with  an  abundant  mucoid  basis-substance,  the  cells  being 
concentrically  arranged  round  the  vessels.  Other  signs  of  the  syj)hilitic 
dyscrasia  are  generally  found  at  the  autopsy. 

(9)  Sarcomata  occur  in  all  varieties  in  the  brain,  and  grow  from  the 
free  surfaces  of  the  interstitial  spaces.  They  appear  as  hard,  slightly 
vascular,  round,  somewhat  nodulated  tumours.  The  soft,  cellular  sarcomata 
present  many  transitions  to  other  forms  of  tumour  indicated  by  the  names 
glio-sarcoma,  myxo-sarcoma,  &c.  One  form  of  spindle-cell  sarcoma  grows 
by  preference  from  the  dura  mater  at  the  base  of  the  brain,  forming 
tuberculated  masses  near  the  sella  Turcica,  and  compressing  the  adjacent 
parts  of  the  brain  and  the  cranial  nerves  at  their  points  of  exit.  In  some 
sarcomatous  tumours  the  spindle-cells  are  arranged  in  concentric  layers 
forming  nests.  This  form  has  been  named  "  nested  sarcoma"  by  Dr. 
Gowers. 

(10)  Lipoma  has  occasionally  been  met  with  on  the  inner  surface  of 
.  the  dura  mater  and  on  the  ventricular  ependyma. 

(11)  Psammomum  is  a  tumour  with  a  basis  of  connective  or  sometimes 
of  mucoid  tissue,  distinguished  by  its  containing  calcareous  concretions. 
It  usually  grows  from  the  membranes  of  the  brain,  and  especially  from 
the  choroid  plexus,  in  which  situation  it  often  contains  numerous  cysts. 
According  to  the  most  recent  investigations  psammomum  is  to  be  regarded, 
not  as  a  distinct  kind  of  tumour,  but  as  a  calcareous  deposit  in  tumours 
of  widely  different  structure  (Dreschfeld). 

(12)  Osteomaia. — If  we  exclude  the  calcifications  of  other  tumours, 
true  formations  of  bone  are  the  rarest  of  all  intracranial  growths.  Osseous 
formations  in  the  dura  mater,  after  injuries,  are  more  common.  Syphilitic 
exostoses,  although  for  the  most  part  arising  from  the  external  table,  yet 
sometimes  spring  from  the  internal  surface  of  the  skull,  and  cause  pres- 
sure on  the  brain  like  other  tumours  in  the  same  locality. 

(13)  Cystic  growths  in  the  brain  are  not  so  common  as  was  formerly 
supposed.      They  are  most  common  in  the  pituitary  body. 

(14)  Angiom,ata  generally  occur  in  the  brain  as  a  complication  of  other 
tumours,  such  as  glioma.  The  growths  on  the  inner  surface  of  the  dm-a 
mater,  described  under  the  name  of  pachymeningitis  haemorrhagica  breg- 
matica,  belong  to  this  class. 

(6)  Aneurisms. 

Aneurisms  of  the  cerebral  arteries  are  not  rare.  They  are  of  various 
sizes,  but  only  those  which  arise  from  the  larger  vessels,  chiefly  at  the 


558         '  FOCAL   DISEASES,   ACCORDING  TO 

base  of  the  brain,  will  come  under  consideration  at  present.  They  gene- 
rally arise  in  consequence  of  atheromatous  degeneration  of  the  vessels. 
The  common  termination  is  in  rupture. 

(c)  Parasites  of  the  Brain. 
The  animal  parasites  which  occur  in  the  cranial  cavity  are  (])  Cysti- 
cercus  cellulosae,  and  (2)  Echinococcus  hominis. 

(1)  Cysticercus  CeUulosce. — Cysticerci  of  the  brain  generally  occur, 
according  to  Eosenthal,  in  the  parts  which  are  richly  supplied  by  vessels, 
such  as  the  ventricles,  the  ganglia  and  their  commissures,  the  pia  mater, 
and  the  cortex  of  the  brain.  They  were  found  23  times  in  the  meninges, 
especially  the  pia  mater,  59  times  in  the  cortex,  32  times  in  the  basal 
ganglia  and  adjacent  commissures,  18  times  in  the  ventricles,  18  times  in 
the  cerebellum,  4  times  in  the  pons,  and  twice  in  the  medulla  oblongata 
(Rosenthal).  The  parasite  is  sometimes  found  in  other  parts  of  the  body 
as  well  as  in  the  brain.  Out  of  88  cases  collected  by  Kuechenmeister, 
the  cysticerci  were  found  1 1  times  in  other  parts  of  the  body.  Cerebral 
cysticerci  are  usually  enclosed  in  a  soft  capsule,  in  which  the  animal  may 
be  seen  with  the  naked  eye  as  a  small  white  tubercle ;  while  its  neck,  with 
the  characteristic  booklets,  may  be  discovered  on  microscopic  examination. 
Cerebral  cysticerci  occur  with  greatest  frequency  in  places  where  cows 
pasture  in  fields  strewn  with  the  excrement  collected  in  cities  (Cobbold). 

(2)  Echinococcus  Hominis. — Echinococcus  cysts  often  reach  a  large  size. 
In  a  case  reported  by  Dr.  Morgan,  the  cyst  was  as  large  as  a  walnut,  and 
weighed  647  grammes.  Of  forty  observations  collected  by  Dr.  Morgan, 
the  cyst  was  situated  10  times  in  the  cerebral  lobes,  8  times  in  the  cere- 
bellum, 4  times  in  the  ventricles,  twice  in  the  ventricles,  and  once  in  the 
pons.  The  cysts  attain  their  greatest  size  in  the  hemispheres,  and  in  the 
lateral  ventricles,  especially  in  children  before  the  fontanelles  are  closed. 
The  cyst  is  composed  of  an  external  fibrous  membrane  which  encloses  the 
parasites ;  its  internal  surface  is  lined  by  small  buds,  each  about  the  size 
of  a  millet  seed,  and  provided  with  the  characteristic  ring  of  booklets. 
The  cavity  of  the  cyst  is  usually  filled  with  a  liquid,  which  is  either  clear 
or  contains  floating  debris  and  secondary  vesicles,  the  buds  of  the  latter 
being  destitute  of  hooks,  and  called  acephalocyst. 

§  733.  Morbid  Physiology. — The  only  part  of  the  physiology 
of  cerebral  tumours  with  which  we  are  here  concerned  is  to 
connect  the  symptoms  with  the  effects  produced  by  the 
growth  upon  the  nervous  tissues.  The  tumour  grows  from  a 
minute  point,  and  gradually  increases  in  circumference,  so  that 
it  is  at  first  almost  entirely  latent,  or  only  gives  rise  to 
indefinite  symptoms.  As  the  tumour  increases  in  size  it  pro- 
duces progressive  general  compression  of  the  whole  brain.     In 


THE  NATURE   OF   THE   LESION.  ,         559 

order  to  make  room  for  the  increasing  size  of  the  tumour,  the 
cerebro-spinal  fluid  is  first  removed,  the  blood  is  then  squeezed 
out  of  the  vessels,  and  the  whole  substance  of  the  brain  suffers 
pressure.  It  is  evident,  therefore,  that  a  process  of  this  nature 
will  ultimately  lead  to  gradual  abolition  of  the  functions  of  the 
brain. 

But  not  only  is  the  brain  subjected  to  general  compression, 
but  the  tissues  surrounding  the  new  growth  are  liable  to  special 
pressure,  which  soon  leads  to  their  destruction.  The  tumour 
itself  must  probably  always  be  regarded  as  a  destroying  lesion, 
and  consequently  its  direct  tendency,  as  a  local  growth,  is  to 
give  rise  to  depressive  symptoms.  It  must,  however,  be  remem- 
bered that  the  abolition  of  the  function  of  a  higher  centre 
may  leave  the  functional  activity  of  a  lower  centre  more  unre- 
strained. 

But  although  the  direct  tendency  of  the  tumour  is  to  destroy 
the  surrounding  tissues,  yet  its  indirect  effect  is  often  irritative. 
The  tumour  acts  as  a  foreign  body,  and  is  liable  to  cause  hyper- 
83mia  and  inflammation  of  the  surrounding  tissues.  Intercurrent 
attacks  of  irritative  symptoms  are  therefore  very  liable  to  take 
place  in  the  course  of  cerebral  tumour,  but  they  are  generally 
followed  by  a  further  extension  of  those  of  depression.  It  must 
also  be  remembered  that  irritation  of  a  higher  centre  may  pro- 
duce an  inhibitory  action  on  a  lower  centre.  But  the  processes 
set  up  in  the  surrounding  tissues  are  not  always  of  an  irritative 
or  inflammatory  nature.  An  artery  may  be  compressed  and 
the  tissues  to  which  it  is  distributed  may  undergo  ischsemic 
softening.  The  veins  in  the  vicinity  of  the  tumour  may  be 
compressed,  giving  rise  to  effusion  of  serum  either  into  the  sur- 
rounding tissues  or  into  the  ventricles  of  the  brain.  Softening 
as  well  as  oedema  of  the  surrounding  tissues,  in  whatever  way 
produced,  must  be  regarded  as  a  destroying  lesion,  and  the 
symptoms  depend  upon  the  situation  and  not  the  nature  of 
the  lesion. 

§  734.  Grouping  of  the  Symptoms. — A  review  of  the  symp- 
toms of  intracranial  tumours  shows  that,  although  they  are 
very  numerous  and  variable,  they  admit  for  practical  purposes 
of  the  following  arrangement: — (1)  General  and  initial  symp- 


560  FOCAL   DISEASES,   ACCORDING  TO 

toms,  which  may  be  present  in  every  kind  of  intracranial 
tumour,  whatever  its  position ;  (2)  Symptoms  caused  by  the 
localisation  of  the  lesion ;  (3)  Intercurrent  symptoms  depend- 
ing on  accessory  lesions  ;  (4)  Terminal  phenomena. 

(1)  Th^  general  and  initial  symptoms  consist  of  headache,  dizziness, 
restlessness,  and  mental  irritability,  parsesthesise,  various  disturbances 
of  the  special  senses,  and  convulsions.  These  symptoms  may  be  present 
individually  or  in  various  combinations,  and  for  a  long  time  they  may  be 
the  only  symptoms  complained  of. 

(2)  The  symptoms  which  depend  upon  the  localisation  of  the  tumour 
do  not  differ  essentially  from  the  symptoms  caused  by  other  focal  diseases 
of  the  brain.  They  result  from  destruction  of  the  surrounding  parts  of  the 
brain  ;  they  are  essentially  paralytic  in  their  character,  although  the  loss 
of  function  may  occasionally  be  preceded  by  transitory  irritative  phe- 
nomena.   -These  symptoms  will  be  more  fully  described  heieafter. 

(3)  The  accessory  lesions  which  give  rise  to  intercurrent  symptoms  are 
hypersemia  and  inflammation  of  the  surrounding  tissues.  The  chief 
symptoms  caused  by  these  lesions  are  hallucinations,  maniacal  and  con- 
vulsive paroxysms,  and  attacks  of  apoplexy  and  meningitis. 

(4)  The  terminal  symptoms  are  caused  by  gradual  and  increasing 
compression  of  the  brain,  and  consist  of  the  progressive  abohtion  of  the 
mental  faculties,  and  general  sensory  and  motor  paralysis,  ending  in  coma. 
In  many  cases  of  cerebral  tumours  death  results  from  an  intercurrent  disease, 
from  an  attack  of  cerebral  hsemorrhage,  or  from  sudden  paralysis  of  the 
respiratory  centre  when  the  tumour  is  situated  in  the  pons  or  upper  end 
of  the  medulla,  or  when  the  ventricles  are  distended  with  serum.  The 
intensity  of  the  symptoms  is  by  no  means  proportional  to  the  size  of 
the  tumour,  inasmuch  as  a  growth  may  sometimes  attain  a  large  size 
without  giving  rise  to  marked  symptoms,  while  at  other  times  a  small- 
sized  tumour  may  give  rise  to  intense  disturbances. 

The  following  are  the  conditions  on  which  the  differences  in  the  in- 
tensity of  the  symptoms  appear  to  depend : — (a)  Idiosyncrasies  of  the 
patient ;  {b)  the  position  of  the  tumour  ;  (c)  the  nature  and  rate  of  growth 
of  the  tumour ;  {d)  the  changes  set  up  in  the  surrounding  tissues  ;  and 
(e)  the  presence  of  several  tumours,  or  the  existence  of  complications. 

(a)  Idiosyncrasies  of  the  Patient.  —  It  is  well  known  that  some  men 
react  much  more  actively  than  others  to  the  same  degree  of  irritation.  A 
degree  of  irritation,  for  instance,  which  would  not  produce  an  appreciable 
effect  on  adults  may  occasion  violent  convulsions  in  children. 

(6)  Position  of  the  Tumour. — Some  parts  of  the  brain  are  tolerant  and 
others  are  very  intolerant  of  displacement  or  any  interference  from  without. 
The  white  substance  of  the  hemispheres  and  the  occipital  lobes  belong  to 
the  first  category  ;  the  medulla,  pons,  and  the  internal  capsule  of  the 
lenticular  nucleus  to  the  second. 


THE   NATURE   OF   THE   LESION.  561 

(c)  Nature,  of  the  Tumoxir  and  its  Rate  of  Growth.  —It  may  be  laid  doM'ii 
as  a  general  rule  that  the  intensity  of  the  symptoms  is  in  direct  pro- 
portion to  the  rapidity  of  the  growth  of  the  tumoiu".  The  slow-growing 
cholesteatomata,  for  instance,  usually  attain  a  considerable  size  before 
giving  rise  to  any  distinctive  symptoms.  When  the  gro-wi;h  is  rapid  there 
is  a  greater  flow  of  blood  to  the  part,  and  the  surrounding  tissues  are  more 
liable  to  undergo  irritative  changes,  while  the  brain  has  no  time  to  accom- 
modate itself  to  the  new  disturbance.  The  increased  bulk  of  the  tumour 
is  sometimes  caused  not  by  growth  of  its  tissue  elements,  but  by  oedema 
or  haemorrhage,  and  then  it  produces  all  the  effects  of  a  sudden  injury 
to  the  brain.  Conducting  fibres  which,  if  pushed  aside  by  a  slow-growing 
tumour,  would  maintain  for  a  long  time  their  fimctional  integrity,  are  now 
suddenly  stretched,  ruptured,  and  irremediably  damaged.  Retrogressive 
changes  within  the  tmnoiirs  may,  according  to  their  nature,  cause  great 
variations  in  the  symptoms.  Sometimes  these  changes  may  lead  to  haemor- 
rhage and  all  its  consequences  ;  while  at  other  times  the  tumoiu-  may  by 
these  changes  become  diminished  in  bulk,  thus  relieving  the  pressure  on 
the  brain  and  leading  to  a  temporary  amelioration  of  the  symptoms. 

{d)  Morbid  Changes  in  the  Surrounding  Tissues. — The  changes  set  up  in 
the  tissues  surrounding  the  tvmioiu-  may  either  constitute  discharging  or 
destroying  lesions.  It  is  not  possible  to  draw  a  clear  line  of  demarcation 
between  these  two  kinds  so  far  as  the  symptoms  are  concerned,  since  the 
effect  of  a  destroying  lesion  in  the  immediate  vicinity  of  the  tumour  may, 
be  obscured  by  those  of  discharging  lesions  in  remote  parts.  In  the  early 
stages  of  the  growth  of  the  tumour  the  discharging  lesions  predominate. 
The  tumour  acts  as  a  mechanical  irritant  or'  foreign  body,  and  it  may 
directly  irritate  the  part  in  which  it  is  situated,  or  indirectly  irritate  remote 
parts  by  reflex  action,  or  again  its  effects  may  be  more  or  less  diffused 
and  general. 

It  is  very  important  to  observe  that  the  symptoms  of  intracranial 
tumours  frequently  intermit  in  the  early  stages  of  the  disease,  and  only 
become  permanent  and  continuous  in  the  latter  stages  when  the  whole 
brain  is  subjected  to  pressure.  The  reasons  for  this  intermittence  of 
symptoms  are  riot  far  to  seek.  A  large  discharge  of  nervous  energy  is 
followed  by  exhaustion,  so  that  the  discharging  lesions  caused  by  the  local 
irritation  of  the  tiunours  are  followed  by  exhaustion,  accompanied  by  tem- 
porary subsidence  of  the  active  symptoms.  At  other  times  the  symptoms 
may  be  caused  not  so  much  by  the  size  of  the  tumour  as  by  oedema  and 
inflammation  of  the  surrounding  tissues,  and  when  the  latter  subside  the 
symptoms  disappear  for  a  time,  although  the  primary  lesion  still  persists. 

(e)  The  Presence  of  several  Tumours  and  Complications. — The  variety 
and  complication  of  symptoms  are  very  much  increased  when  several 
tumours  are  present,  or  when  symptoms  of  tumour  are  associated  with 
cerebral  disturbance  caused  by  an  independent  affection,  such  as  Bright's 
disease.  • 

KK 


562  FOCAL   DISEASES,   ACCORDING  TO 

§  735,  Diagnosis. — Intracranial  tumours  may  be  confounded 
with  other  cerebral  lesions,  and  indeed  at  an  early  stage  it  is 
almost  impossible  to  be  sure  of  the  diagnosis.  The  most 
important  symptom  of  tumour  is  to  be  found  in  the  optic  discs. 
Many  cases  are  recorded  in  which  the  presence  of  double  optic 
neuritis  was  the  only  symptom  that  could  lead  one  to  the 
suspicion  of  cerebral  tumour,  and  in  which  the  diagnosis  was 
subsequently  justified  by  the  progress  of  the  case.  Two  cases 
of  this  kind  have  come  under  my  own  observation,  and  the 
occurrence  of  such  cases  has  led  Dr.  Hughlings-Jackson  to  insist 
on  the  routine  use  of  the  ophthalmoscope  in  the  examination 
of  patients. 

In  tubercle  the  disease  of  the  brain  is  generally  associated 
with  tuberculous  affections  of  other  organs,  and  a  hereditary 
predisposition  to  the  disease  can  usually  be  ascertained. 

Hydrocephalus,  in  its  chronic  form,  is  a  frequent  accompa- 
niment of  tumour,  especially  when  the  latter  is  situated  under 
the  tentorium,  where  the  growth  is  liable  to  produce  pressure 
on  the  venae  Galeni  magnse,  or  to  prevent  the  return  of  the 
cerebro-spinal  fluid  into  the  spinal  canal. 

Apoplexy  occurs  in  advanced  age,  its  onset  is  sudden,  and 
it  is  usually  associated  with  disease  of  the  heart,  atheroma 
of  the  vessels,  and  granular  kidney ;  while  the  paralysis  is 
sudden,  without  premonitory  symptoms,  and  frequently  followed 
by  late  rigidity  in  the  extremities.  Tumour,  on  the  other  hand, 
occurs  at  every  time  of  life  without  being  necessarily  associated 
with  other  diseases,  while  the  paralysis  comes  on  slowly  and 
increases  gradually,  and  is  preceded  by  other  symptoms,  such 
as  violent  cephalalgia,  vomiting,  vertigo,  and  neuralgia,  and  it 
is  rarely  followed  by  late  rigidity.  They  may  be  further  dis- 
tinguished from  each  other  by  the  double  optic  neuritis  of 
cerebral  tumour,  in  opposition  to  the  rarer  unilateral  embolic 
amaurosis  of  apoplexy.  Care,  however,  must  be  taken  not  to 
confound  one  form  of  albuminuric  retinitis  with  the  optic 
neuritis  of  cerebral  tumour. 

In  chronic  softening  the  paroxysms  of  headache  are  less  fre- 
quent and  intense  than  in  tumour,  while  affections  of  the  special 
senses  and  ansesthesia  of  the  cephalic  nerves  occur  more  fre- 
quently in  tumour  than  in  softening ;  on  the  other  hand  the 


THE   NATURE   OF   THE   LESION.  563 

occurrence  of  sudden  and  complete  hemiplegia  and  aphasia  is 
more  common  in  softening  than  in  tumour.  Alternate  and 
bilateral  paralysis  occur,  according  to  Hasse,  frequently  in 
tumour  and  only  exceptionally  in  softening. 

Abscess  of  the  brain  is  to  some  extent  similar  to  tumour  in 
its  physical  relations,  inasmuch  as  it  may  produce  increase  of 
intracranial  pressure,  and,  like  tumour,  the  tissues  surrounding 
the  diseased  focus  are  often  affected  by  inflammatory  attacks. 
Abscess  usually  occurs  as  the  direct  consequence  of  an  injury, 
such  as  fractures  of  the  skull  and  concussions  of  the  brain,  or 
associated  with  some  other  disease,  such  as  caries  of  the  petrous 
portion  of  the  temporal  bone,  ozsena,  foci  of  suppuration,  diseased 
vessels,  or  valvular  diseases  of  the  heart;  while  tumour  is  never 
more  than  a  remote  consequence  of  an  injury.  In  tumour  the 
cephalalgia  is  severe,  the  various  symptoms  assume  a  progressive 
character,  and  there  is  usually  a  gradual  extinction  of  the 
functions  of  the  brain;  or  apoplexy  may  occur,  but  meningitis 
is  rare. 

Atrophy  of  the  brain  produces  an  early  destruction  of  the 
mental  activities  which  passes  gradually  into  imbecility.  The 
presence  of  tremors  of  the  lips,  tongue,  and  limbs,  of  epilepti- 
form convulsions,  hemiplegia  or  paraplegia,  and  loss  of  mental 
power,  form  a  group  of  symptoms  so  characteristic  that  they 
cannot  well  be  mistaken  for  those  of  tumour. 

Hypertrophy  of  the  brain  of  children  gives  rise  to  symptoms 
as  cephalalgia  and  epileptiform  convulsions  somewhat  similar 
to  those  of  tumour.  The  large  circumference  of  the  great 
fontanelle,  with  its  strong  pulsation,  the  slow  dilatation  of 
the  head,  the  distinct  traces  of  rickets  in  the  skeleton,  and 
spasms  of  the  larynx  combine  to  prevent  this  disease  from  being 
mistaken  for  cerebral  tumour. 

Syphilis  of  the  brain  may  give  rise  to  symptoms  closely 
simulating  those  of  cerebral  tumour,  and  indeed  the  presence  of 
a  distinct  gumma  induces  symptoms  which  are  identical  with 
the  symptoms  of  other  forms  of  tumour.  The  history  of  the 
case,  permanent  traces  of  the  disease  such  as  cicatrices,  the 
peculiar  pains  of  the  nerves  and  bones,  epileptiform  convulsions, 
and  evidences  of  the  presence  of  more  than  one  focus  of  disease, 
are  amongst  the  signs  to  be  made  use  of  in  forming  a  diagnosis. 


564  FOCAL   DISEASES,   ACCORDING   TO 

§  786.  Diagnosis  of  the  nature  of  the  Tumour. — It  is  not 
always  possible  to  diagnose  the  nature  of  the  tumour,  although 
this  may  be  done  sometimes  with  a  considerable  degree  of  cer- 
tainty. The  development  of  glioma  is  frequently  preceded  by 
an  injury  to  the  skull,  the  progress  of  the  symptoms  is  slow, 
and  the  illness  is  consequently  of  comparatively  long  duration. 
Hsemorrhage  not  unfrequently  occurs  into  the  substance  of  the 
tumour  or  into  the  surrounding  tissues,  and  the  patient  is, 
therefore,  liable  to  suffer  from  intercurrent  attacks  of  apoplexy. 

Tiirbercular  tumour  may  be  suspected  when  the  symptoms 
of  intracranial  tumour  occur  in  childhood,  and  when  a  heredi- 
tary predisposition  to  tubercle  can  be  traced.  The  diagnosis  is 
rendered  more  certain  when  evidence  of  tuberculosis  in  other 
organs  or  cheesy  degeneration  of  the  glands  can  be  detected. 
The  tumour  is  also  more  likely  to  be  of  a  tubercular  nature 
when  the  symptoms  indicate  that  it  is  situated  in  the  cere- 
bellum, or  that  multiple  lesions  are  present.  Tubercular 
tumour  often  begins  after  an  acute  febrile  disease,  as  measles 
or  scarlet  fever,  while  its  progress  is  frequently  complicated  by 
slight  attacks  of  meningitis. 

Carcinoma  of  the  brain  is  characterised  by  the  rapid  pro- 
gress of  the  symptoms,  and  the  presence  of  the  cancerous 
cachexia  or  evidence  of  the  deposition  of  cancer  in  other  organs. 

Sarcom,ata  are  not  easily  diagnosticated  during  life,  but  when 
the  most  prominent  symptoms  are  afforded  by  compression  of 
the  nerves  at  the  base  of  the  brain  sarcoma  may  be  suspected. 

Syphilomata  of  the  brain  will  be  subsequently  described  in 
detail. 

Cysticercus  cellulosce,  when  situated  in  the  brain,  often  re- 
mains latent  for  a  comparatively  long  period.  The  more  usual 
symptoms  of  the  affection  are  headache  and  vertigo,  followed 
by  muscular  spasms,  epileptiform  convulsions,  and  various 
mental  disturbances,  but  distinct  paralysis  is  rare.  The  con- 
vulsions caused  by  the  presence  of  the  parasite  may  at  first 
be  similar  in  every  respect  to  those  of  idiopathic  epilepsy,  but 
in  the  terminal  period  the  attacks  increase  in  number  and 
violence,  as  many  as  80  to  100  daily  having  been  known  to 
occur  during  the  week  previous  to  death  (Rosenthal).  The 
psychical    disturbances    consist   at  first    of  illusions,   delirium, 


THE   NATURE   OF   THE   LESION.  565 

maniacal  attacks,  followed  by  melancholy,  somnolency,  and 
stupor.  The  diagnosis  of  the  presence  of  cysticerci  is  rendered 
more  probable  if,  in  addition  to  the  symptoms  just  described, 
the  history  of  the  case  show  that  the  patient  had  previously 
suffered  from  taenia,  or  if  the  patient  be  a  butcher  or  pork 
dealer. 

Echinococcus  hominis,  when  found  in  the  brain,  does  not 
give  rise  to  characteristic  symptoms.  The  most  constant  symp- 
toms are  headache,  vertigo,  vomiting,  tremors,  epileptiform 
attacks,  and  the  usual  evidences  of  the  presence  of  an  intra- 
cranial tumour  in  the  optic  discs.  In  the  cases  collected  by 
Dr.  Morgan  the  duration  of  the  symptoms  averaged  one  and  a 
half  years.  The  tumour  may  sometimes  make  its  way  through 
the  cranial  bones.  In  Reeb's  case  it  made  its  way  through 
the  parietal  bone,  while  in  a  case  observed  by  Westphal  two 
openings  were  found  in  the  frontal  bone  through  which  the 
tumour  projected ;  an  incision  having  been  made  90  vesicles 
flowed  through  the  opening,  and  the  case  terminated  in  recovery. 
Westphal  states  that  the  diagnosis  of  the  presence  of  echino- 
cocci  in  the  brain  must  be  made  from  the  general  symptoms  of 
intracranial  tumour  appearing  and  disappearing  alternately, 
oedema  of  the  eyelids,  an  opening  in  the  cranial  bones  through 
which  a  fluctuating  tumour  projects,  or  exploratory  puncture. 

Aneurism  of  the  cerebral  arteries  gives  rise  to  symptoms  like 
those  of  other  tumours  situated  at  the  base  of  the  brain,  nor 
are  there  any  sure  signs  by  means  of  which  the  former  may  be 
distinguished  from  the  latter.  Even  auscultation  of  the  skull 
has  not  hitherto  proved  of  much  use  in  the  diagnosis  of  intra- 
cranial aneurism.  If  aneurism  of  any  of  the  other  vessels  of 
the  body  co-exist  with  the  symptoms  of  tumour  situated  at  the 
base  of  the  skull,  then  aneurism  of  one  of  the  cerebral  vessels 
may  be  suspected.  It  is  probable  that  aneurism  gives  rise  to 
more  pronounced  symptoms  of  irritation,  such  as  intense  cepha- 
lalgia, paroxysms  of  severe  and  intractable  trifacial  neuralgia, 
attacks  of  mania  and  other  grave  psychical  disorders,  than 
solid  growths.  If  a  patient,  who  has  been  suffering  from  the 
symptoms  of  tumour  situated  at  the  base  of  the  brain,  die 
suddenly  from  an  attack  of  ingravescent  apoplexy,  it  may  be 
conjectured  that  the  tumour  was  an  aneurism  rather  than  a 


566  FOCAL  DISEASES,   ACCORDING  TO 

new  formation.  If  a  case,  in  which  the  patient  has  suffered 
from  the  symptoms  of  tumour  situated  in  the  anterior  fossa  of 
the  skull,  terminate  fatally  from  a  copious  haemorrhage  from 
the  nose,  it  may  be  assumed  with  considerable  probability  that 
an  aneurism  of  the  anterior  cerebral  artery  has  perforated  the 
cribriform  plate  of  the  ethnoid  bone.  If  pulsation  and  a  mur- 
mur on  auscultation  be  observed  in  the  orbit  immediately  after 
an  injury  to  the  skull,  it  is  probable  that  a  communication  has 
been  established  between  the  internal  carotid  artery  and  the 
cavernous  sinus  (Lebert). 

§  737.  Prognosis. — With  the  exception  of  syphilitic  cases, 
death  is  the  usual  consequence  of  cerebral  tumours.  Even  a 
syphilitic  tumour  may  not  be  amenable  to  treatment  if  it  be  of 
long  standing,  since  irreparable  mischief  to  the  brain  may  have 
already  been  caused  by  it.  Cases  of  cerebral  tumour  may  some- 
times terminate  in  sudden  death  through  an  attack  of  apoplexy 
or  of  convulsions,  or  occasionally  without  evident  cause.  In 
other  cases  the  symptoms  may  become  quiescent,  the  vomiting 
cease,  the  amaurosis  even  disappear,  and  the  patient  regard 
himself  cured.  After  a  time,  however,  the  symptoms  usually 
recur  with  increased  intensity,  and  lead  to  a  fatal  termination. 

§  738.  TreatTiient. — In  the  large  majority  of  cases  very  little 
can  be  done  by  treatment,  but  even  in  these  unpromising 
cases  curative  efforts  should  not  be  abandoned.  In  the  earlier 
stages  of  cerebral  tumours  the  symptoms  are  generally  those  of 
irritation  and  of  local  congestion,  and  these  must  be  treated  by 
cold  to  the  head,  purgatives,  and  occasionally  by  the  use  of 
flying  blisters. 

The  cephalalgia  may  be  combated  by  ice  to  the  head,  and  if 
no  relief  be  afforded,  narcotics  are  to  be  cautiously  resorted  to. 
Subcutaneous  injections  of  morphia  will  be  found  the  most 
useful  and  reliable  remedy,  although  small  doses  of  belladonna 
have  occasionally  been  attended  with  benefit.  The  chloride  of 
ammonium  may  occasionally  be  found  useful. 

When  convulsions  are  a  prominent  symptom,  doses  of  from 
half  a  drachm  to  a  drachm  of  the  bromide  of  potassium  may  be 
useful. 


THE   NATURE    OF    THE   LESION.  567 

With  the  view  of  promoting  absorption  of  the  morbid  growth, 
iodide  of  potassium  has  been  administered  in  large  doses  and 
with  apparent  benefit.  For  adults  half-drachm  doses  may  be 
given  to  begin  with,  and  increased  until  a  drachm  is  taken 
three  times  a  day.  Of  course  if  there  be  evidence  of  syphilis, 
energetic  anti-syphilitic  treatment  by  means  of  mercury  and 
iodide  of  potassium  is  indicated. 


568 


CHAPTER  VI. 


(II.)     SPECIAL     CONSIDERATION     OF     FOCAL     DISEASES, 
ACCORDING  TO  THE  LOCALISATION  OF  THE  LESION. 


1.    AFFECTIONS    OF    THE    PEDUNCULAR    FIBRES    AND 
INTERNAL    CAPSULE. 

a.  Affections  of  the  Pyramidal  Tract. 
(i.)    Hemiplegia. 

§  739.  Hemiplegia  consists  of  paralysis  of  one-half  of  the 
body,  although  many  of  the  muscles  are  either  not  implicated  or 
only  temporarily  weakened.  The  paralysis  is,  as  a  rule,  limited 
to  the  arm,  leg,  and  part  of  the  face. 

In  facial  paralysis  of  cerebral  origin  the  cheek  on  the  affected 
side  looks  flat,  the  corresponding  naso-labial  fold  is  obliterated, 
the  upper  lip  is  less  arched,  and  the  angle  of  the  mouth  is 
lowered  on  the  affected  side,  the  distortion  becoming  more 
marked  when  the  facial  muscles  of  the  healthy  side  contract. 
Paralysis  of  the  orbicularis  oris  interferes  with  the  pronunciation 
of  the  labials  and  with  such  actions  as  whistling  and  blowing 
out  a  candle.  The  patient  can  frown  as  usual,  raise  his  eye- 
brow and  eyelid  and  close  his  eye  on  the  paralysed  almost  as 
well  as  on  the  healthy  side,  but  is  unable  to  perform  a  uni- 
lateral action  like  winking  on  the  affected  side.  The  facial 
paralysis  begins  usually  to  disappear  in  a  few  weeks,  and  some- 
times in  a  few  days,  while  it  may  persist  for  months.  The 
muscles  chiefly  affected  in  facial  paralysis  of  cerebral  origin 
are  the  buccinator,  orbicularis  oris,  and  the  straight  muscles 
which  pass  to  the  angle  of  the  mouth  and  to  the  nose  on  the 
paralysed  side;  while  the  occipito-fron talis,  corrugator  super- 


FOCAL   DISEASES.  569 

cilii,  and  orbicularis  oculi  remain  almost  entirely  unaffected. 
In  facial  paralysis  of  peripheral  origin  all  the  muscles  supplied 
by  the  facial  nerve  below  the  lesion  are  equally  paralysed. 

The  hypoglossal  nerve  is  affected  in  most  cases  of  apoplexy, 
as  shown  by  a  certain  degree  of  difficulty  in  executing  the 
movements  of  the  tongue.  On  protrusion  its  point  deviates 
more  or  less  to  the  paralysed  side,  the  base  being  dragged 
further  forwards  on  the  healthy  side.  The  affection  of  the 
tongue,  as  a  rule,  disappears  in  a  short  time,  but  is  occasionally 
permanent. 

Some  observers  state  that  the  muscles  of  the  trunk  are  un- 
affected in  hemiplegia,  but  the  inspiratory  muscles  undoubtedly 
act  less  freely  on  the  paralysed  side  for  the  first  few  days  in 
severe  cases. 

(ii.)    Hemispasm. 

§  740.  The  spasms  which  occur  in  connection  with  focal 
cerebral  lesions  are  of  three  kinds :  (a)  Tonic,  (b)  combined 
tonic  and  clonic,  and  (c)  clonic  spasms. 

(a)  Tonic  Spasms. — The  tonic  contractions  which  occur  in 
connection  Avith  focal  lesions  of  the  brain  may  be  divided  into 
two  classes  :  (i.)  Early  and  (ii.)  late  rigidity. 

(i.)  Early  Rigidity. — The  contractions  which  occur  in  early- 
rigidity  may  be  subdivided  into  those  which  immediately  ac- 
company the  haemorrhage,  and  those  which  occur  a  few  days 
after  the  attack.  The  contractions  of  the  first  kind  are 
probably  produced  by  irritation  of  the  fibres  of  the  pyramidal 
tract,  occasioned  either  by  rupture  or  partial  injury.  The 
second  form  of  early  rigidity  appears  in  the  paralysed  parts  a 
few  days  after  the  occurrence  of  hsemorrhage,  and  during  the 
time  inflammatory  changes  are  taking  place  in  the  tissues  sur- 
rounding the  clot.  These  contractions,  therefore,  are  probably 
also  the  result  of  irritation  of  the  fibres  of  the  pyramidal 
tract.  Early  rigidity  may  be  so  slight  as  only  to  be  manifest 
when  passive  movement  of  the  paralysed  extremity  is  made. 
When  the  arm  is  flexed,  for  instance,  if  an  attempt  be  made  to 
straighten  it,  the  biceps  offers  resistance  to  the  movement; 
while  at  other  times  resistance  is  offered  to  flexion  by  con- 
traction of  the  triceps. 


570  FOCAL  DISEASES,   ACCORDING   TO 

The  rigidity  may  sometimes  be  limited  to  the  fingers,  while 
at  other  times  the  arm  is  drawn  to  the  side  of  the  chest,  the 
elbow  and  wrist  are  firmly  bent,  the  fingers  are  flexed  upon  the 
palm,  and  all  attempts  to  extend  the  limb  increase  the  con- 
tractions, and  cause  pain  as  well  as  some  amount  of  tremor  or 
slight  clonic  spasm.  The  resistance  yields  occasionally  under 
steady  pressure.  This  form  of  rigidity  may  affect  the  leg  as 
well  as  the  arm,  and  then  the  thigh  becomes  flexed  on  the 
trunk,  and  the  leg  on  the  thigh,  so  that  the  heel  is  brought  up 
to  the  buttock.  Early  rigidity  generally  disappears  soon,  but 
may  persist  for  weeks  or  months.  The  affected  muscles  do 
not  undergo  atrophy,  their  faradic  and  reflex  excitability  is 
increased,  and  they  become  completely  relaxed  during  sleep, 
although  the  spasm  recurs  immediately  on  the  patient  awaking. 
The  appearance  of  early  rigidity  diminishes  the  chances  of  the 
patient's  recovery,  and  when  it  continues  for  a  long  time  changes 
take  place  in  the  muscles,  tendons,  and  joints  of  the  affected 
extremities,  which  ultimately  leave  them  permanently  contracted 
and  useless. 

(ii.)  Late  Rigidity. — This  form  of  contracture  is  caused  by 
descending  degeneration  of  the  fibres  of  the  pyramidal  tract, 
and  corresponds  in  its  essential  character  to  the  spasmodic 
rigidity  of  primary  lateral  sclerosis.  Its  most  characteristic 
feature  is  the  exaggeration  of  the  tendinous  and  periosteal 
reflexes.  When  the  lower  extremity  is  affected  the  patellar- 
reflex  is  in  excess,  and  ankle-clonus  is  readily  elicited,  and 
corresponding  phenomena  may  be  obtained  in  the  upper  ex- 
tremity when  it  becomes  the  subject  of  contracture.  When 
the  loss  of  voluntary  power  is  complete,  the  rigidity  is  more  or 
less  constant,  although  it  is  in  most  cases  diminished  during 
sleep  and  increased  during  voluntary  efforts  and  emotional 
disturbances. 

The  attitudes  assumed  by  the  limbs  affected  with  late 
rigidity  differ  considerably  in  different  cases,  but  on  the  whole 
they  conform  to  the  rule  observed  in  almost  all  spasmodic 
affections,  namely,  that  flexion  predominates  in  the  upper,  and 
extension  in  the  lower  extremity.  In  the  most  usual  attitude 
of  the  upper  extremity  the  arm  is  drawn  towards  the  trunk  by 
contraction  of  the  pectoralis  major.     The  forearm  is  semi-flexed 


f 

.V 

( 

•I 

'i 

i 

THE   LOCALISATION   OF   THE   LESION.  571 

on  the  arm  and  pronated,  the  hand  is  slightly  flexed  on  the 
forearm,  and  the  fingers  are  closed.  In  some  cases  the  forearm, 
instead  of  being  semi-flexed  and  pronated,  is  semi-flexed  and 
supinated.  In  a  few  rare  cases  the  forearm  is  extended  upon 
the  arm,  and  then  the  forearm  may  either  be  in  a  state  of 
supination  or  pronation  (Charcot).  Probably  the  most  frequent 
attitude  of  the  hand  is  that  in  which  the  fingers  are  ex- 
tended at  the  metacarpo-phalangeal  and  flexed  at  the  phalangeal 
joints  (Gowers).  The  inferior  extremity  is,  as  a  rule,  main- 
tained in  a  state  of  rigid  extension,  the  foot  being  in  the  posi- 
tion of  talipes  equino-varus.  In  some  few  cases  flexion  pre- 
dominates over  extension  in  the  lower  extremity,  and  then  the 
thigh  becomes  flexed  on  the  trunk,  and  the  legs  on  the  thigh, 
so  that  the  heel  touches  the  buttock.  In  these  cases  the  con- 
tracture is  apt  to  extend  to  the  opposite  extremity,  and  then 
station  and  locomotion  are  impossible.  In  some  cases  the  con- 
tracture extends  to  the  inferior  muscles  of  the  face.  The  con- 
tracture is  at  first  transitory,  and  only  manifested  when  the 
patient  laughs  or  cries,  but  after  a  time  it  becomes  permanent. 
The  angle  of  the  mouth  on  the  affected  side  is  then  elevated, 
the  naso-labial  fold  is  increased  in  depth,  and  even  the  eye  of 
the  corresponding  side  may  be  smaller  than  the  healthy  eye 
(Plate  VI,  2,  3,  and  4). 

After  a  time,  however,  the  muscles  may  undergo  progressive 
atrophy,  and  the  contractures  almost  entirely  disappear,  although 
the  bones  and  ligaments  having  become  adapted  to  the  form  in 
which  the  limb  has  so  long  been  maintained  the  deformity 
persists.  In  these  cases  it  is  probable  that  the  descending 
degeneration  of  the  lateral  column  of  the  spinal  cord  has  ex- 
tended to  the  ganglion  cells  of  the  anterior  grey  horns.  The 
muscles  which  do  not  suffer  at  all,  or  suffer  least,  from  late 
rigidity  are  those  that  are  bilaterally  associated  in  their  actions, 
while  those  acting  independently  of  the  corresponding  muscles  of 
the  other  side  are  most  affected.  In  accordance  with  this  rule,  the 
muscles  of  the  trunk  remain  unaffected,  and  the  muscles  of  the 
lower  extremity  are  less  frequently  and  less  profoundly  affected 
than  those  of  the  upper ;  the  superior  muscles  of  the  face 
generally  escape,  while  the  inferior  facial  muscles  are  occasion- 
ally attacked.   The  rigidity,  however,  is  not  always  so  fixed  and 


572  FOCAL   DISEASES,   ACCORDING   TO 

unvarying  as  that  just  described.  It  may  never  become  fully 
established,  or  after  having  become  established  may  undergo  a 
considerable  amount  of  improvement.  When  the  rigidity  has 
never  been  fully  established,  it  may  be  observed  that  the  tension 
becomes  less  when  the  limb  is  warm  and  greater  when  it  is 
cold  ;  that  it  can  be  diminished  by  gently  rubbing  the  muscles  ; 
and  that  it  disappears  almost,  if  not  entirely,  during  sleep.  On 
the  other  hand,  the  rigidity  is  increased  during  voluntary  efforts 
to  move  the  limb,  this  effect  being  more  marked  when  the 
patient  is  under  observation. 

Although  rigidity  may  have  become  fully  established,  at  the 
end  of  some  months  it  gradually  diminishes  to  such  a  degree 
that  Brissaud  proposes  to  call  the  condition  latent  contracture. 
The  patient  may  perform  all  the  simple  movements  of  the  limb, 
and  probably  with  undiminished  power,  but  whenever  his  atten- 
tion is  specially  directed  to  the  movements,  as  when  he  wishes 
to  perform  any  manual  operation  requiring  a  little  dexterity, 
the  muscles  instantly  become  rigid,  the  fingers  are  flexed  on 
the  palm,  and  the  deformity  which  was  present  during  the 
period  of  fixed  contracture  reappears.  It  may  also  be  shown 
that  the  tendon  reflexes  continue  exaggerated,  although  the 
muscular  tension  has  in  great  part  disappeared.  It  is  not  3^et 
ascertained  whether  the  disappearance  of  the  muscular  tension 
is  due  to  a  corresponding  repair  of  the  fibres  of  the  injured 
pyramidal  tract  on  the  opposite  side,  or  to  the  establishment 
of  new  connections  with  the  cortex  of  the  brain  on  the  same 
side  through  commissural  fibres  in  the  cord. 

(6)  Combined  Tonic  and  Clonic  Spasms. — The  cases  just 
described,  in  which  a  slight  degree  of  muscular  tension  per- 
manently present  in  the  affected  extremity  is  associated  with 
marked  spasm  on  a  voluntary  effort  being  made  to  move  the 
limb,  form  a  fitting  transition  to  those  cases  in  which  a  fixed 
tonic  contraction  of  some  of  the  muscles  is  associated  with 
clonic  contractions  of  others.  In  the  combined  tonic  and  clonic 
varieties  of  post-hemiplegic  motor  disorders,  the  muscular  con- 
tractions are  at  first  entirely  like  those  which  occur  in  late 
rigidity,  but  after  a  time  some  of  the  muscles  implicated 
become  the  subjects  of  clonic  spasm. 

Varieties. — The  combined  tonic  and  clonic  spasms  of  hemi- 


THE   LOCALISATION   OF   THE   LESION.  573 

plegic  limbs  consist  of  the  following  varieties  : — (i.)  Intermittent 
tremor,  and  (ii.)  Choreiform  movements. 

(i.)  Intermittent  Tremor. — The  most  usual  form  of  tremor 
observed  in  hemiplegia  limbs  corresponds  with  that  which  is 
observed  in  spastic  spinal  paralysis.  The  tendon  reflexes  are 
exaggerated,  and  the  tremor  is  induced  when  the  muscles  are 
put  upon  the  stretch  by  any  attempt  at  voluntary  movement 
or  otherwise.  This  kind  of  tremor  is  therefore  similar  to  that 
described  as  "  spinal  epilepsy  "  in  lateral  sclerosis  of  the  spinal 
cord,  and,  like  the  latter,  it  is  associated  with  descending 
sclerosis  of  the  pyramidal  tract.  The  tremor  is,  like  that  of 
multiple  sclerosis,  absent  during  repose. 

The  muscles  of  hemiplegic  limbs  are  liable  to  be  affected 
with  fibrillary  contractions  similar  to  those  which  occur  in 
progressive  muscular  atrophy  and  amyotrophic  lateral  sclerosis. 
It  is  probable  that  muscular  atrophy  is  always  associated  with 
these  contractions  in  hemiplegia,  and  that  the  descendiug 
changes  of  the  pyramidal  tract  have  extended  to  the  ganglion 
cells  of  the  anterior  grey  horns  of  the  cord. 

(ii.)  GhoreiforTn  Movements. — Clonic  choreiform  spasms  of 
the  extremities  may  either  precede  or  follow  an  attack  of  hemi- 
plegia, the  former  being  named  pre-hemiplegic,  and  the  latter 
post- hemiplegic  chorea  (Weir  Mitchell,  Charcot).  In  pre- 
hemiplegic  chorea  the  patient  complains  of  a  feeling  of  numb- 
ness and  feebleness  of  the  extremities  of  one  side,  his  gait 
becomes  hesitating  and  irregular,  and  the  upper  extremity  of 
the  affected  side  is  attaked  by  choreiform  movements.-  These- 
symptoms  may  continue  for  some  days,  when  complete  hemi- 
plegia, usually  associated  with  hemiansesthesia,  is  either  sud- 
denly or  gradually  established.  Post-hemiplegic  chorea  occurs 
in  partially  but  never  in  completely  paralysed  limbs,  and  Usually 
appears  simultaneously  with  a  marked  diminution  of  the  para- 
lytic symptoms.  The  clonic  spasms  as  a  rule  become  gradually 
established  as  motor  power  returns,  although  they  sometimes 
supervene  suddenly,  and  appear  to  be  sometimes  induced  by  a 
strenuous  voluntary  effort  on  the  part  of  the  patient  to  move 
the  paralysed  limb.  Clonic  spasms  occur  more  frequently  in 
the  arm  than  in  the  leg,  and  when  they  exist  in  both  they  are 
more  severe  in  the  former,  while  if  the  leg  be  exclusively  affected' 


574  FOCAL   DISEASES,   ACCORDING   TO 

the  arm  is  usually  completely  paralysed.  The  muscles  of  the 
face  are  sometimes  affected  by  those  spasms,  causing  various 
distortions,  which  become  greatly  increased  when  the  patient 
laughs  or  cries. 

The  movements  affected  by  choreiform  spasm  in  the  upper 
extremity  are,  in  decreasing  order  of  frequency,  the  special 
movements  of  the  fingers  and  thumb,  flexion  and  extension  of 
the  wrist,  pronation  and  supination  of  the  forearm,  extension 
and  flexion  at  the  elbow,  and  movements  at  the  shoulder-joint. 
The  iuterossei  are  particulary  liable  to  be  affected  by  chorei- 
form spasm,  and  consequently  the  movements  most  frequently 
observed  consist  of  varying  degrees  of  flexion  and  extension  at 
the  metacarpo-phalangeal  articulations,  associated  respectively 
with  extension  and  flexion  at  the  phalangeal  articulations.  The 
movements  induced  by  these  spasms  are  of  wider  range  than 
those  of  hemiplegic  tremor,  resembling  in  this  respect  the 
movements  of  chorea.  They  are  disorderly  and  irregular,  and 
may  or  may  not  continue  during  complete  repose ;  they  cease 
during  sleep,  and  become  much  aggravated  during  voluntary 
efforts  to  perform  a  definite  movement  with  the  affected  limb, 
such  as  that  of  raising  a  glass  of  water  to  the  mouth.  When 
the  lower  extremity  is  affected,  the  whole  body  may  be  thrown 
into  a  state  of  agitation  during  locomotion. 

Two  forms  of  jpost-henni'plegic  chorea  may  be  distinguished : 
(a)  the  post-hemiplegic  chorea  of  adults ;  and  (^)  the  spastic 
hemiplegic  of  infancy.  The  spastic  hemiplegia  of  infancy  may 
consist  of  a  purely  tonic  spasm  of  the  muscles  without  any 
admixture  of  clonic  spasms,  although  the  choreiform  variety  is 
probably  the  more  common. 

(a)  Post-hemiplegic  Chorea  of  Adults. — The  post-hemiplegic 
chorea  of  adults  and  the  corresponding  affection  of  infancy  differ 
iu  various  ways.  In  the  former  the  history  of  the  case  shows 
that  the  attack  of  hemiplegia  which  preceded  the  appearance 
of  the  clonic  spasms  occurred  during  adult  life,  or  at  any  rate 
not  in  early  mfancy.  The  attack  of  hemiplegia  may  have  occa- 
sionally become  gradually  established  when  due  to  the  slow 
growth  of  a  tumour,  but  as  a  rule  it  has  come  on  suddenly  with 
apoplectic  symptoms.  An  examination  of  the  patient  may 
reveal  valvular  disease  of  the  heart,  or  there  may  be  a  history 


THE   LOCALISATION   OF   THE   LESION.  575 

of  injury  to  the  head.  The  post-hemiplegic  chorea  of  adults, 
apart  from  the  history,  differs  from  that  of  infancy  in  the  co- 
existence of  hemianaesthesia  in  the  former  and  its  absence  in 
the  latter.  The  ansesthesia  extends  over  the  lateral  half  of  the 
body ;  and  all  forms  of  sensibility,  including  the  special  senses, 
are  more  or  less  affected.  Three  distinct  cases  of  the  post- 
hemiplegic chorea  of  adults  have  come  under  my  own  obser- 
vation. All  the  patients  were  comparatively  young  men,  their 
ages  ranging  from  25  to  33  years.  The  attack  of  hemiplegia, 
which  had  preceded  the  choreiform  movements,  occurred  in 
each  several  years  previously  to  my  seeing  them.  Two  of  the 
patients  presented  evidence  of  slight  stenosis  of  the  mitral 
valve,  and  in  the  third  the  apoplectic  attack  had  been  induced 
by  a  fall  on  the  head.  The  attitude  assumed  by  the  affected 
arm  was  very  similar  in  the  three  cases.  There  was  marked 
tonic  spasm  of  the  posterior  third  of  the  deltoid  in  all  of  them, 
so  that  the  elbow  was  abducted  from  the  trunk  to  the  extent  of 
about  two  and  a  half  inches,  while  it  was  also  drawn  backwards 
considerably  behind  the  posterior  plane  of  the  body.  The  fore- 
arm was  slightly  flexed  on  the  arm  and  strongly  pronated,  the 
hand  was  slightly  flexed  on  the  forearm,  while  the  fingers  were 
kept  in  constant  movement  by  clonic  spasms  of  the  interossei 
muscles.  There  was  also  a  certain  degree  of  spasmodic  pro- 
nation and  supination  of  the  forearm  and  flexion  and  extension 
of  the  hand  in  all;  while  in  one,  irregular  jerking  movements 
of  the  forearm,  hand,  and  fingers  occurred  when  the  patient 
attempted  to  grasp  any  object  with  the  paralysed  hand.  A 
marked  feature  presented  by  these  cases  was  the  fact  that  each 
patient  carried  the  affected  hand  in  the  out  pocket  of  his  coat, 
in  order  to  arrest  its  disorderly  movements.  In  this  position 
the  upper  arm  was  directed  downwards,  outwards,  and  back- 
wards from  the  shoulder,  the  elbow  being  considerably  removed 
from  the  trunk  and  behind  its  posterior  plane,  the  forearm  was 
slightly  bent  on  the  arm,  and  the  back  of  the  hand  was  pressed 
closely  against  the  hip. 

In  the  three  patients  referred  to  the  tactile  sensibility  of  the 
palm  and  fingers  of  the  affected  hand  was  remarkably  deficient. 
When  the  patient  was  asked  to  close  his  hand  on  a  coin  placed 
on  the  palm,  with  his  eyes  closed,  he  could  not  say  whether  he 


576  FOCAL   DISEASES,  ACCORDING  TO 

had  or  had  not  the  coin  in  his  grasp ;  and  when  the  coin  was 
withdrawn  before  the  closure  of  the  fingers,  it  was  amusing  to 
observe  his  puzzled  expression  on  opening  his  eyes  and  hand 
when  he  found  the  latter  empty.  The  patients  could  be  pricked 
with  a  pin  over  half  the  face,  trunk,  and  over  extremities  on 
the  affected  side  almost  without  pain.  In  one  of  these  cases 
all  forms  of  cutaneous  sensibility,  and  the  muscular  sense,  were 
diminished  over  half  of  the  body  on  the  affected  side,  the  senses 
of  taste  and  smell  were  also  diminished  on  the  corresponding 
side,  but  the  senses  of  hearing  and  sight  were  not  affected  to 
an  appreciable  extent, 

(/?)  Spastic  Hemiplegia  of  Infancy. — In  the  spastic  hemi- 
plegia of  infancy  the  lesion  which  determines  the  paralysis 
occurs  during  birth,  or  in  early  infancy.  The  paralysis 
appears  sometimes  to  have  become  established  before  birth, 
but  cases  of  this  kind  are  exceptional.  It  is,  however,  not 
uncommon  to  ascertain,  on  inquiry  from  the  parents,  that  the 
patient  who  is  affected  with  the  spastic  hemiplegia  of  infancy 
suffered  from  repeated  convulsions  accompanied  by  uncon- 
sciousness for  the  first  two  or  three  days  after  birth,  although 
it  may  not  be  observed  that  the  child  is  paralysed  on  one  half  -of 
the  body  till  some  time  subsequently.  In  the  majority  of  these 
patients,  however,  the  onset  of  the  disease  dates  from  the  age 
of  two  to  three  months  to  that  of  four  or  five  years.  The  most 
usual  history  is  that  after  an  illness  of  indefinite  character  ex- 
tending over  a  few  days,  or  without  any  warning,  the  child  has 
been  taken  with  convulsions.  These  convulsions,  as  a  rule,  have 
recurred  repeatedly  for  some  hours  or  days,  the  child  remaining  in 
the  meantime  in  a  state  of  unconsciousness.  In  many  cases  this  is 
the  only  history  which  can  be  obtained,  but  where  the  parents 
are  intelligent  it  may  be  ascertained  that  the  convulsions 
were  limited  to  the  side  of  the  body  which  had  subsequently 
become  paralysed.  Many  infants  doubtless  die  during  these 
convulsions  or  a  few  days  after,  but  in  the  cases  which 
survive  it  is  soon  observed  that  one  half  of  the  body  is 
paralysed.  The  hemiplegia  in  these  cases  pursues  the  usual 
course,  contractures  become  established,  and  choreiform  move- 
ments may  or  may  not  make  their  appearance  during  partial 
recovery,  but  when  once  these  movements  appear  they  remain 


THE   LOCALISATION    OF   THE   LESION.  577 

permanent.  So  far,  then,  these  cases  present  nothing  peculiar 
except  that  the  disease  dates  from  childhood,  that  it  is  ushered 
in  by  convulsions  and  profound  unconsciousness,  and  that  the 
motor  paralysis  is  not  accompanied  by  hemiansesthesia. 

In  the  spastic  hemiplegia  of  childhood,  however,  it  is  soon 
observed  that  the  intellect  of  the  patient,  however  bright  the 
child  may  have  been  previous  to  the  attacks  of  convulsions 
which  marked  the  onset  of  the  disease,  has  become  markedly 
defective.  This  form  of  hemiplegia  is,  indeed,  nearly  always 
associated  with  some  degree  of  idiocy. 

Another  marked  peculiarity  of  the  affection  is  that  at  a  cer- 
tain age  the  hemiplegia  becomes  associated  with  epilepsy.  The 
epileptic  attacks  generally  begin  when  the  patient  is  from  seven 
to  fifteen  years  of  age,  and  at  first  are  usually  limited  to  the 
paralysed  side  of  the  body,  and  may  not  be  attended  by  decided 
loss  of  consciousness.  In  the  case  of  a  well-developed  girl  four- 
teen years  of  age,  under  my  care,  suffering  from  the  spastic 
hemiplegia  of  childhood,  the  epileptic  attacks  began  when  she 
was  eight  years  of  age.  The  right  half  of  the  body  was. 
paralysed,  the  arm  being  more  paralysed  than  the  leg,  both 
limbs  were  somewhat  rigid,  but  neither  manifested  any  chorei- 
form movements.  The  epileptic  attack  always  began  by  move- 
ments of  the  paralysed  arm  ;  these  soon  extended  to  the  muscles 
of  the  mouth  on  the  same  side,  and  then  to  the  paralysed  leg. 
In  most  attacks  this  patient  became  unconscious  for  a  few 
moments,  and  then  got  up  and  walked  about  as  if  nothing 
had  happened.  In  some,  however,  the  convulsions  were 
limited  to  the  paralysed  arm,  with  probably  a  slight  exten- 
sion of  them  to  the  angle  of  the  mouth,  but  the  leg  remained 
free,  and  there  was  no  loss  of  consciousness.  The  patient  was 
once  reported  by  the  nurse  to  have  walked  across  the  ward 
during  an  attack,  holding  down  the  convulsed  and  paralysed 
arm  with  the  opposite  hand.  In  old-established  cases  the  con- 
vulsions may  become  general,  but  it  may  be  observed  that  they 
retain  a  unilateral  character  at  the  commencement  of  the  attack, 
and  the  patient  usually  describes  a  unilateral  aura. 

The  aura  is  often  described  as  a  sensation  beginning  in  the 
paralysed  hand,  and  ascending  along  the  arm  to  the  shoulder 
and  head,  when  unconsciousness  supervenes.     At  other  times 

LL 


578  FOCAL  DISEASES,   ACCORDING  TO 

the  sensation  begins  in  the  paralysed  leg,  and  ascends  succes- 
sively to  the  arm  and  head.  In  several  cases  under  the  care  of 
Mr.  Hardie,  which  I  examined  recently  in  Crumpsall Workhouse, 
three  of  which  are  represented  in  Plate  VI.,  Figs.  2,  3,  and  4,  the 
patients  could  not  give  any  account  of  an  aura;  and  so  far  as  I 
could  judge  from  the  account  given  by  their  attendants,  the  con- 
vulsions did  not  assume  a  unilateral  character.  In  all  these 
cases  marked  idiocy  was  present,  so  that  the  presence  of  an  aura 
could  not  be  determined  from  the  inability  of  the  patients  to 
describe  it.  In  one  case  of  the  kind,  with  choreiform  move- 
ments of  the  paralysed  hand,  sent  to  me  by  Mr.  CuUingworth, 
the  patient  had  an  epileptic  attack  once  while  I  was  examining 
her.  I  could  not  observe-that  the  convulsions  assumed  a  pro- 
Dounced  unilateral  character  at  any  time  during  the  attack.  On 
cross-examining  her  with  respect  to  the  aura,  she  positively 
denied  that  she  had  had  any  warning  whatever  of  impending 
attacks;  but  after  a  time  she  volunteered  the  statement, 
"  When  the  fits  began  first  I  used  to  have  a  creeping  feeling 
in  the  leg,  which  came  up  to  the  arm,"  at  the  same  time 
pointing  successively  to  the  paralysed  leg  and  arm. 

These  patients  also  present  other  phenomena  which  are 
worthy  of  notice,  the  most  remarkable  of  which  is  an  arrest 
of  development  of  the  paralysed  limbs,  generally  implicating 
the  corresponding  side  of  the  face.  The  circumference  of  the 
paralysed  extremities  is  usually  less  than  that  of  corresponding 
parts  of  the  opposite  limbs,  although  not  always  so.  Where  a 
limb  is  subject  to  violent  choreiform  movements,  the  muscles 
may  become  hypertrophied  so  that  its  circumference  exceeds 
that  of  the  corresponding  healthy  extremity.  But  even  under 
these  circumstances  it  may  be  found  that  the  circumference  of 
the  bones  on  the  affected  side  is  less  than  that  of  the  sound 
side,  and  that  the  enlargement  is  limited  to  the  muscles.  Each 
of  the  long  bones  of  the  affected  extremities  may  be  from  ^in. 
to  lin,  shorter  than  the  corresponding  bones  of  the  affected 
side,  and  even  the  clavicle  of  the  paralysed  side  may  be  from 
|in.  to  ^in.  shorter  than  the  opposite  clavicle.  The  diminution 
of  size  of  half  the  face  may  extend  to  all  the  features,  inclu- 
dmg  the  eyebrows,  eyelids,  half  of  the  nose,  the  cheek,  and  half 
the  mouth. 


THE   LOCALISATION   OF   THE  LESION.  579 

(c)  Clonic  Spasms. — The  post-hemiplegic  motor  disorders, 
which  consist  of  clonic  spasms  unaccompanied  by  tonic  con- 
tractions of  the  muscles,  are  (i.)  continuous  or  remittent  tremor, 
(ii.)  choreiform  movements  (athetosis),  and  (iii.)  jerking  move- 
ments on  voluntary  effort  (hemiataxia). 

(i.)  Continuous  or  Remittent  Tremor. — The  tremor  which 
has  already  been  described  as  occurring  in  hemiplegic  limbs 
was  associated  with  increased  muscular  tension,  excess  of  the 
tendon  reflexes,  and  only  occurred  when  a  voluntary  movement 
of  the  limb  was  made.  In  the  form  of  tremor  about  to  be 
described,  muscular  tension,  if  present  in  excess  at  all,  is  not  a 
prominent  feature  of  the  case,  the  tendon  reflexes  are  not 
exaggerated,  the  tremor  is  continuous  at  least  during  waking 
hours,  and  instead  of  being  exaggerated  it  may  be  diminished 
or  arrested  by  a  voluntary  effort.  We  have  seen  that  the  first 
form  of  tremor  is  like  that  which  is  observed  in  sclerosis  in 
patches;  while  the  second  form  is  in  all  essential  particulars 
like  the  tremors  of  paralysis  agitans.  A  case  of  the  latter  kind 
has  been  described  by  Grasset.  The  tremors,  which  continued 
during  repose,  were  accompanied  by  sensations  of  heat  like 
those  complained  of  by  patients  suffering  from  paralysis  agitans. 
A  case  is  described  by  Leyden  in  which  tremors  occurred  in  the 
right  arm,  momentarily  arrested  by  a  voluntary  effort,  while 
there  was  complete  absence  of  any  paralysis  or  contractures  and 
of  sensory  disturbances.  A  round  sarcomatous  tumour  was  found 
in  the  left  optic  thalamus.  By  the  courtesy  of  Dr.  Leech,  I 
had  an  opportunity  of  showing  to  the  members  of  the  British 
Medical  Association  at  the  Manchester  meeting,  a  case  in  which 
one-half  of  the  body  presented  all  the  characteristics  of  a 
moderately  advanced  paralysis  agitans.  The  tremors  extended 
to  the  right  foot,  leg,  and  one-half  of  the  trunk;  while  the  atti- 
tude of  the  forearm,  fingers,  and  thumb  was  quite  characteristic. 
The  symptoms  supervened  nine  months  previously,  and  were 
preceded  by  a  slight  attack  of  confusion,  not  amounting  to  un- 
consciousness, followed  by  slight  paresis  of  the  right  side  of  the 
body. 

(ii.)  Athetosis. — An  affection  has  been  described  by. Ham- 
mond under  the  name  of  athetosis,  in  which  the  patient  is 
unable  to  maintain  the  fingers  or  toes  in  fixed  positions.     The 


580  FOCAL   DISEASES,   ACCORDING  TO 

fingers  and  toes  in  this  affection  are  maintained  in  continuous 
slow  movement,  and  are  made  to  assume  various  distorted 
positions.  These  movements  are  not  always  limited  to  the 
fingers  and  toes,  but  extend  to  the  hand  and  foot,  and  occasion- 
ally even  to  the  muscles  of  the  neck  and  face.  No  motor 
weakness  has  been  recognised,  the  movements  are  only  to  a  slight 
extent  under  the  control  of  the  will,  they  usually  persist  during 
sleep,  and  are  not  accompanied  by  contractures.  Cases  of  the 
affection  have  been  described  by  AUbutt,  Currie  Ritchie,  Fisher 
(Boston,  U.S.),  Gairdner,  and  others,  while  Claye  Shaw  and 
Dreschfeld  have  drawn  attention  to  the  analagous  condition 
sometimes  observed  in  the  limbs  of  imbecile  children.  Oulmont 
has  written  a  valuable  monograph  of  the  whole  subject. 

The  appearance  of  the  clonic  spasm  is  in  almost  all  cases 
preceded  by  a  distinct  attack  of  hemiplegia,  and  when  no 
decided  paralysis  can  be  ascertained  to  have  been  present  the 
history  of  the  case  shows  that  the  patient  has  suffered  from  an 
attack  of  convulsions  and  unconsciousness. 

Hemiansesthesia  is  described  as  being  present  on  the  affected 
side  in  some  of  the  reported  cases,  while  a  certain  degree  of 
numbness  of  the  same  side  is  frequently  mentioned.  In  a  con- 
siderable number  of  cases  the  condition  of  sensibility  is  not 
mentioned,  and  probably  no  special  attention  was  directed  to 
the  point. 

The  affected  extremity  usually  presents  vaso-motor  disturb- 
ances. It  is  red  or  livid,  moist,  and  colder  than  the  corre- 
sponding extremity. 

The  affected  hand  or  foot  is  also  frequently  atrophied ; 
although  the  muscles  which  are  affected  by  the  spasm  may 
undergo  a  certain  amount  of  hypertrophy.  The  electric  con- 
tractility of  the  affected  muscles  varies  in  different  cases,  being 
sometimes  normal,  at  other  times  enfeebled  or  increased. 

Oulmont  has  observed  an  unusual  degree  of  relaxation  of  the 
ligaments  and  joints  of  the  affected  extremities. 

A  bilateral  athetosis  has  been  described  by  Oulmont.  It 
does  not  differ  essentially  from  the  unilateral  affection,  except 
that  the  muscles  of  the  face  appear  to  be  more  liable  to  be  im- 
plicated to  a  greater  extent  in  the  former.  The  bilateral  affec- 
tion is  generally  associated  with  idiocy,  but  may  occur  without 


THE   LOCALISATION    OF   THE   LESION.  581 

this  complication.  It  is  not,  according  to  Oulmont,  preceded 
by  apoplexy  or  hemiplegia,  and  is  unaccompanied  by  sensory 
disturbances. 

(iii.)  Hemiataxia.—A  case  has  been  described  by  Dr.  Gowers 
in  which  there  was  great  inco-ordination  of  the  right  arm 
during  voluntary  movement,  while  there  was  complete  absence 
of  permanent  rigidity  and  spontaneous  spasm.  The  patient 
had  suffered  from  a  slight  attack  of  apoplexy  followed  by  hemi- 
plegia a  year  and  a  half  before  he  came  under  observation,  but 
the  paralysis  had  disappeared,  a  slight  weakness  of  the  arm, 
leg,  and  face  alone  remaining.  The  ataxic  movements  of  the 
arm  became  exaggerated  on  the  eyes  being  closed.  Tactile 
sensibility  was  diminished  in  the  right  arm,  but  sensibility  to 
pain  was  normal.  In  a  somewhat  similar  case  recorded  by  the 
same  observer  the  autopsy  revealed  "a  puckered  cicatrix" 
passing  through  the  left  thalamus  from  the  one  side  to  the  other. 
A  case  in  which  ataxic  movements  occurred  in  the  right  hand  is 
also  described  by  Grasset.  The  patient  had  a  series  of  apoplectic 
attacks  followed  by  hemiplegia  and  a  certain  embarrassment  of 
speech.  The  ataxic  movements  were  limited  to  the  right  arm, 
the  paralysis  being  more  marked  in  the  face  and  arm  than  in 
the  leg.  At  the  autopsy  three  centres  of  softening  were  found 
in  the  left  hemisphere.  The  first  occupied  the  region  of  the 
lenticulo-striate  artery ;  the  second  was  in  the  optic  thalamus 
close  to  its  ventricular  border ;  and  the  third  was  found  in  the 
thalamus  close  to  the  posterior  portion  of  the  internal  capsule. 

§  741.  The  Hemiplegic  Walk — When  the  muscles  of  the 
paralysed  lower  extremity  have  acquired  a  certain  degree  of 
rigidity,  the  patient  is  able  to  walk  by  the  aid  of  a  stick,  even 
if  the  voluntary  paralysis  of  the  affected  side  remain  complete. 
The  patient  leans  towards  the  healthy  side,  but  is  prevented 
from  falling  over  to  that  side  by  the  support  of  the  stick ;  the 
pelvis  and  hip-joint  of  the  paralysed  side  are  elevated  by 
contraction  of  the  abductors  of  the  opposite  thigh,  so  that  the 
weight  is  taken  off  the  paralysed  extremity.  When  the 
paralysed  lower  extremity,  say  the  right  leg,  is  the  active  one, 
the  line  of  gravity  is  carried  over  to  a  slight  extent  to  that 
side;  but  instead  of  reaching  the  centre  of  the  paralysed  foot, 


582  FOCAL   DISEASES,  ACCORDING   TO 

it  remains  midway  between  it  and  the  end  of  the  stick,  so  that 
the  weight  of  the  body  is  maintained  partly  by  the  paralysed 
lower  extremity  and  partly  by  the  healthy  arm  through  the 
stick.  The  healthy  or  left  lower  extremity  is  now  quickly 
moved  forwards  a  step,  an  unusual  degree  of  flexion  of  the  thigh 
upon  the  body  taking  place  in  order  to  avoid  the  necessity  of 
carrying  the  line  of  gravity  too  far  to  the  paralysed  side.  The 
left  leg  now  becomes  active,  and  the  paralysed  one  must  be 
moved  forwards.  The  manner  in  which  this  movement  is  exe- 
cuted depends  upon  the  degree  of  paralysis  and  of  muscular 
rigidity  present.  If  the  paralysis  be  almost  complete  and  the 
rigidity  not  great,  the  extremity  is  partly  swung  and  partly 
dragged  round  mainly  by  the  contraction  of  the  inward  rotators 
of  the  healthy  limb.  Contraction  of  these  muscles  causes  the 
pelvis  to  rotate  forwards  on  the  hip-joint  of  the  healthy  side,  and 
consequently  the  opposite  hip-joint,  dragging  after  it  the  para- 
lysed leg,  is  moved  forwards.  This  forward  movement  is  aided 
by  a  further  elevation  of  the  right  hip-joint  caused  by  contrac- 
tion of  the  abductors  of  the  opposite  thigh,  and  sometimes  by 
a  slight  backward  inclination  of  the  trunk  by  means  of  which 
the  distance  between  the  points  of  origin  and  insertion  of  the 
flexors  of  the  thigh  on  the  body  is  increased. 

If  a  high  degree  of  contracture  with  talipes  equinus  be  pre- 
sent, the  paralysed  lower  extremity  is  moved  forwards  much  in 
the  same  manner  as  has  already  been  described  in  the  case  of 
primary  lateral  sclerosis.  When  once  the  weight  of  the  body 
is  taken  off  the  paralysed  extremity  the  heel  becomes  elevated, 
and  the  toe  during  the  forward  movement,  which  takes  place  in 
a  semicircular  manner,  makes  a  characteristic  scraping  noise. 

If  tremors  or  choreoid  movements  be  present  in  the  paralysed 
lower  extremity,  the  hemiplegic  walk  may  become  modified  in 
such  numerous  ways  as  to  render  it  impossible  to  comprise  the 
different  varieties  which  may  be  presented  in  a  single  description. 

b.  Affections  of  the  Sensory  Peduncular  Tract  and 
Optic  Radiations  of  Gratiolet. 

Hemianesthesia. 
§  742. — In  cerebral  hemianajsthesia  the  affection  develops 
suddenly  after  an  attack  of  apoplexy,  or  gradually  as  the  result. 


i 


THE   LOCALISATION   OF   THE   LESION.  583 

for  instance,  of  the  progressive  growth  of  a  tumour.  The 
sensibility  is  diminished  over  the  whole  of  one-half  of  the 
body,  face,  and  extremities,  including  the  accessible  mucous 
membranes  as  well  as  the  skin.  The  abolition  of  sensation 
is  sometimes  incomplete,  and  then  cutaneous  analgesia  or 
thermo-angesthesia  may  be  present,  while  tactile  sensibility 
remains  unaffected.  At  other  times  the  ansesthesia  of  the  skin 
and  mucous  membranes  is  complete,  and  even  muscular  sen- 
sibility and  muscular  sense  are  abolished.  The  patient,  for 
instance,  does  not  feel  deep  pressure,  strong  contraction  of  the 
muscles  may  be  produced  by  the  faradic  current  without 
causing  pain,  and  when  his  eyes  are  closed  he  is  unable  to 
describe  the  position  in  which  the  affected  extremities  may  be 
placed  by  passive  movements,  and  is  not  aware  when  his 
attempted  voluntary  movements  are  forcibly  prevented.  The 
patient  can  walk  without  difficulty  when  his  eyes  are  closed, 
but  by  slight  pressure  upon  the  affected  side  he  may  be  easily 
induced  to  walk  in  a  circle  while  under  the  impression  that  he 
is  walking  in  a  straight  line. 

One-half  of  the  mucous  membrane  of  the  tangue,  mouth, 
and  veil  of  the  palate,  and  the  conjunctiva  of  the  same  side, 
are  insensitive,  but  the  cornea  retains  its  sensibility. 

The  affected  side  is  colder,  and  the  prick  of  a  pin  does  not 
bleed  so  readily  as  on  the  opposite  half  of  the  body. 

The  cutaneous  reflex  actions  may  be  abolished  on  the  side 
affected,  while  the  deep  reflexes  are  retained. 

The  senses  of  taste  and  smell  are  both  abolished  on  the 
affected  side. 

The  sense  of  hearing  is  also  diminished,  and  in  some  cases 
there  may  be  complete  unilateral  deafness. 

The  sense  of  sight  is  impaired  but  not  abolished,  but  hemi- 
opia  has  not  been  observed  when  the  lesion  is  limited  to  the 
internal  capsule.  The  acuteness  of  vision  may  be  tested  in 
the  usual  manner  by  Snellen's  scale.  There  is  also  concentric 
restriction  of  the  field  of  vision,  and  the  perception  of  certain 
colours  may  entirely  cease  (dyschromatopsia). 

§  743.  Morbid  Anatomy  and  Physiology. — It  is  impossible 
to  separate  lesions  of  the   internal   capsule  and  crusta  from 


584  FOCAL   DISEASES,   ACCOKDING  TO 

those  of  the  ganglia  by  which  they  are  surrounded.  Since  the 
days  of  Willis  and  Morgagni  up  to  a  few  years  ago,  paralysis  of 
one-half  of  the  body  has  been  associated  with  disease  of  the 
corpus  striatum.  This  doctrine  had  indeed  received  a  shock 
upwards  of  twenty  years  ago,  from  the  observations  of  Tiirck, 
who  showed  that  hemiansesthesia  of  the  opposite  side  of  the 
body  might  result  from  disease  situated  in  the  posterior  part 
of  the  lenticular  nucleus.  It  was  also  suggested  by  Meynert 
and  Broadbent  that  some  of  the  fibres  of  the  crusta  passed 
upwards  to  reach  the  cortex  of  the  brain  without  being  in  any 
way  connected  with  the  basal  ganglia;  and  Charcot,  with  his 
usual  readiness  and  skill  in  utilising  the  details  of  anatomical 
research  for  clinical  purposes,  suggested,  and  soon  proved  by 
observation  and  analysis  of  cases,  that  both  hemiplegia  and 
hemianaesthesia  are  caused  by  injury  of  the  direct  fibres  which 
lie  between  the  basal  ganglia,  and  not  by  lesions  of  the  ganglia 
themselves.  We  have  already  seen  that  the  fibres  of  the 
posterior  third  of  the  posterior  segment  of  the  internal  capsule 
are  sensory  ;  that  those  of  its  middle  third  connect  the  mecha- 
nisms in  the  cortex  of  the  brain  and  spinal  cord  which  regulate 
the  fundamental  actions ;  that  those  of  the  anterior  third  of  the 
posterior  division  connect  the  mechanisms  which  regulate  the 
specialised  actions ;  and  that  those  in  the  knee  and  the  anterior 
segment  of  the  capsule  connect  the  mechanisms  which  regulate 
the  most  specialised  actions.  Speaking  broadly,  it  may  be  said 
that  the  fibres  of  the  middle  third  of  the  posterior  segment  of 
the  capsule  are  concerned  in  regulating  the  actions  of  the  trunk, 
lower  extremities,  and  probably  the  general  actions  of  the  upper 
extremities  ;  that  the  fibres  of  the  anterior  third  of  the  posterior 
segment  are  concerned  in  regulating  the  more  special  move- 
ments of  the  hand  as  an  organ  of  prehension,  and  probably  also 
the  movements  of  rotation  of  the  head  and  neck,  along  with 
the  associated  ocular  movements ;  and  that  the  fibres  of  the 
knee  of  the  capsule  and  the  adjoining  part  of  the  anterior 
segment  of  the  capsule  are  concerned  in  the  regulation  of  the 
movements  of  facial  expression,  articulation,  and  the  most 
special  movements  of  the  hand,  as  those  of  writing. 

Of  all  the  arteries  of  the  brain  the  lenticulo-striate  artery 
is,  according  to  Charcot,  the  one  which  is  most  liable  to  rupture. 


THE   LOCALISATION   OF   THE   LESION. 


585 


This  artery  lies,  as  we  have  seen,  between  the  external  capsule 
and  the  external  surface  of  the  third  division  of  the  lenticular 
nucleus.  When  this  vessel  ruptures,  if  the  haemorrhage  be 
small,  it  may  lodge  between  the  external  capsule  and  the  lenti- 
cular nucleus,  and  give  rise  to  no  symptoms  (Charcot).  The 
vessel,  however,  being  a  comparatively  large  one,  the  hgemor- 
rhage,  as  a  rule,  extends  beyond  these  limits.  It  is  sometimes 
directed  upwards  between  the  external  capsule  and  the  lenti- 
cular nucleus,  and  may  then  extend  for  a  considerable  distance 
into  the  centrum  ovale.  Under  these  circumstances  the  fibres 
of  the  internal  capsule  become  ruptured  at  their  point  of  emer- 
gence from  between  the  basal  ganglia  where  they  form  the  foot 
of  the  corona  radiata.  Haemorrhages  in  this  situation  may 
be  so  extensive  as  to  extend  upwards  to  the  summits  of  the 

Fig.  242. 


Fig.  242  (Modified  from  Charcot).  Vertical  Section  of  the  Brain  a  little  behind  the 
Knee  of  the  Internal  Capsule,  showing  the  effects  of  rupture  of  the  lenticulo- 
striate  artery.  —NG,  Head,  and  NG',  Tail  of  the  caudate  nucleus ;  Gh, 
Chiasma  ;  NL,  Lenticular  micleus  ;  IK,  Internal  capsule  ;  Cls,  Claustrum  ; 
1,  The  most  frequent  position  in  which  the  lenticulo-striate  artery  is  ruptured  ; 
r,  1",  1'",  Progressive  extension  of  the  haemorrhage  producing  compression  and 
rupture  of  the  fibres  of  the  pyramidal  tract  (hemiplegia) ;  2,  Primary  focus  in 
the  internal  capsule ;  2',  2",  2'",  Successive  extension  of  the  clot. 


58(j  FOCAL   DISEASES,   ACCORDING   TO 

ascending  frontal  and  parietal  convolutions,  while  the  cortex  of 
the  Island  of  Reil  is  conapressed  by  the  clot,  but  the  external 
capsule  is  rarely  ruptured.  At  other  times  the  haemorrhage 
is  directed  inwards  through  the  grey  matter  of  the  lenticular 
nucleus ;  and  if  it  be  large,  it  must  impinge  upon  and  rup- 
ture the  fibres  of  the  internal  capsule,  and  when  these  fibres 
give  way  the  haemorrhage  may  make  its  way  into  the  lateral 
ventricles,  then  through  the  foramen  of  Monroe  into  the  third, 
and  through  the  aqueduct  of  Sylvius  into  the  fourth  ventricle. 

If  the  haemorrhage  remain  limited  to  the  space  between  the 
external  capsule  and  lenticular  nucleus,  it  produces  no  symptoms 
during  life;  but  when  it  makes  its  way  into  the  substance  of 
the  lenticular  nucleus,  or  into  the  centrum  ovale  above  the 
nucleus,  the  fibres  of  the  pyramidal  tract  are  compressed,  and 
hemiplegia  of  the  opposite  side  of  the  body  results.  If  the 
fibres  of  the  pyramidal  tract,  however,  remain  intact,  the 
patient  will  recover  more  or  less  completely  from  the  paralysis. 
A  case  which  came  under  my  observation  several  years  ago  was 
that  of  an  old  man  who  died  a  few  hours  after  being  knocked 
down  by  a  cab  when  crossing  a  street.  The  left  lenticular 
nucleus  was  completely  destroyed,  and  its  usual  position  was 
occupied  by  a  cyst  containing  serous  fluid.  No  good  history  of 
the  case  was  procurable,  but  he  was  not  supposed  to  be  suffering 
at  the  time  of  the  injury  from  any  form  of  paralysis.  A  still 
more  striking  case  will  be  subsequently  described,  in  which  both 
lenticular  nuclei  were  converted  into  cysts,  the  symptoms  during 
life  being  those  of  bulbar  paralysis  without  any  evidence  of 
paralysis  of  the  extremities.  When  the  haemorrhage  remains 
limited  to  the  lenticular  nucleus,  not  only  does  the  patient  ulti- 
mately recover  the  full  use  of  his  limbs,  but  the  apoplectic 
symptoms  during  the  attack  are  slight.  The  patient  complains 
of  giddiness,  there  may  be  vomiting,  and  confusion  of  ideas, 
but  he  does  not  lose  consciousness,  or  the  loss  is  transitory. 
When,  however,  some  or  all  of  the  fibres  of  the  internal  cap- 
sule rupture,  the  larger  size  of  the  clot  produces  a  more  pro- 
found immediate  effect,  while  injury  to  the  fibres  of  the  pyra- 
midal tract  gives  rise  to  a  paralysis  which  remains  permanent. 
The  degree  and  extent  of  the  paralysis  will,  of  course,  depend 
upon  the  extent  of  the  injury  done  to  the  motor  tract.     It  is 


THE   LOCALISATION   OF   THE   LESION. 


587 


probable  that  the  first  form  of  early  rigidity  occurs  during  the 
time  the  fibres  of  the  tract  are  being  stretched  or  ruptured  by 
the  haemorrhage;  the  second  form  of  early  rigidity  is  again 
probably  caused  by  irritation  of  these  fibres,  caused  by  inflam- 
matory changes  in  the  tissues  surrounding  the  clot ;  while  late 
rigidity  is  caused  either  directly  or  indirectly  by  descending 
degeneration  of  the  ruptured  fibres.  But  if  the  haemorrhage 
make  its  way  either  between  the  ascending  longitudinal  fibres 
of  the  corona  radiata,  so  that  a  large  clot  forms  in  the  centrum 
ovale,  or  if  it  rupture  into  the  lateral  ventricle,  profound  symp- 
toms of  coma  supervene,  and  the  patient  dies  in  a  short  time. 

We  have  seen  that  the  comparatively  unyielding  wall  formed 
by  the  external  capsule  directs  haemorrhage  from  the  lenticulo- 
striate  artery  inwards,  and  consequently  the  full  force  of  the 
blood  will  impinge  against  the  internal  capsule  at  a  point  a  little 
behind  its  knee,  or  at  the  point  where  embryological  considera- 

FiG.  243. 


Fig.  243.  Horizontal  Section  of  the  Basal  Ganglia  and  Internal  Capsule  in  an 
embryo  of  nine  months.— NO,  Caudate  nucleus ;  Tff,  Optic  thalamus;  IIV, 
Island  of  Eeil ;  //,  ///,  Second  and  third  segments  of  the  lenticular  nucleus  ; 
pc,  Sensory  peduncular  tract ;  P,  Fundamental,  and  P',  Mixed  portion,  and 
P)  Geniculate  fasciculus  of  the  pyramidal  tract;  c,  Anterior  segment  of  the 
internal  capsule. 


588  FOCAL   DISEASES,   ACCORDING   TO 

tions  had  led  us  to  believe  those  fibres  to  pass,  which  connect 
with  each  other  the  nervous  mechanisms  in  the  cortex  and  spinal 
cord  that  regulate  the  movements  of  the  hand.  In  hsemorrhage 
from  this  artery,  therefore,  the  upper  extremity  is  more  paralysed 
than  either  the  lower  extremity  or  face.  Eupture  of  the  anterior 
branches  of  the  artery  may  injure  the  anterior  segment  of  the 
capsule  to  a  greater  extent  than,  the  posterior  segment,  and 
then  facial  paralysis  predominates.  The  fibres  which  conduct 
those  impressions  from  the  cortex  which  cause  rotation  of  the 
head  and  eyes  to  the  opposite  side  probably  also  pass  in  the 
anterior  third  of  the  posterior  segment  of  the  internal  capsule, 
and  OD  the  side  of  the  capsule  which  adjoins  the  lenticular 
nucleus,  and  they  also  must  be  ruptured  by  a  moderately-sized 

Fig.  244. 


CLs- 


Fig.  244  (Modified  from  Charcot).  Vertical  Section  of  the  Brain  on  a  level  loith  the 
Posterior  Part  of  the  Internal  Capsule,  showing  the  effects  of  rupture  of  the 
lenticulo-optic  artery  (hemianesthesia).— iVC,  NC,  Tail  of  the  caudate  nucleus; 
NL,  Lenticular  nucleus ;  TH,  Optic  thalamus ;  Cls,  Claustruni ;  1,  Primary 
■  focus  in  the  posterior  part  of  the  external  capsule  (hemiansesthesia) ;  1',  1",  1"', 
Progressive  extension  of  the  primary  focus  causing  compression  or  destruction 
of  the  internal  capsule ;  2,  Primary  focus  in  the  internal  capsule  (hemianses- 
thesia) ;  2',  2",  2'",  Successive  extension  of  the  focus. 


THE    LOCALISATION    OF    TEE    LESION.  589 

hsemorrhage  of  the  lenticulo-striate  artery,  but  the  conjugate 
deviation  which  results  is  as  usual  only  a  transitory  symptom 
(§  90).  Hsemorrhage  of  the  lenticulo-optic  artery  is  also  directed 
inwards  against  the  fibres  of  the  internal  capsule  by  the  un- 
yielding walls  of  the  external  capsule,  and  its  greatest  force 
impinges  against  the  posterior  half  of  the  posterior  segment  of 
the  capsule.  It  is  evident,  therefore,  that  hsemorrhage  from 
this  vessel  will  tend  to  injure  the  sensory  peduncular  fibres  and 
the  fibres  of  the  fundamental  mechanism,  but  inasmuch  as  the 
muscles  of  the  trunk  are  bilaterally  associated,  the  paralysis 
resulting  from  injury  of  the  latter  fibres  will  be  more  marked 
in  the  leg  than  in  any  other  part  of  the  body.  An  analysis  of 
clinical  records  had  led  Dr.  Hus^hlinors-Jackson  long  as^o  to  con- 
elude  that  the  form  of  hemiplegia  in  which  the  leg  is  more 
profoundly  affected  than  the  arm  is  generally  associated  with 
hemiansesthesia.  The  fibres  of  Gratiolet  are  not  usually  affected 
in  hsemorrhage  from  the  opto-striate  artery,  and  consequently 
the  special  senses  are  not  always  implicated  in  the  ansesthesia. 

The  anterior  segment  of  the  internal  capsule  is  frequently 
injured  by  lesions  of  the  head  of  the  caudate  nucleus,  the 
resulting  hemiplegia  of  the  opposite  side  being  thus  more 
marked  in  the  face  than  arm,  and  in  the  arm  than  leg,  while 
sensibility  is  seldom  affected. 

Cases  are  recorded  of  lesions  of  old  date  having  been  found 
at  the  autopsy  without  paralytic  symptoms  having  been  present 
during  life  (Nothnagel,  Samt).  In  a  case  of  this  kind  recently 
described  by  Honegger  there  were  no  descending  changes  ob- 
served in  the  crusta,  medulla  oblongata,  or  spinal  cord,  although 
the  fibres  of  the  middle  third  of  the  posterior  segment  of  the 
internal  capsule  in  the  left  hemisphere  appear  to  have  been  in 
great  part  destroyed. 

The  internal  capsule  may  be  injured  by  lesions  of  the  optic 
thalamus.  Hsemorrhage  from  the  posterior  internal  optic  artery, 
if  small,  does  not  appear  to  give  rise  to  any  definite  symptoms, 
and  certainly  not  to  permanent  paralysis.  A  large  hsemorrhage 
from  the  vessel  generally  makes  its  way  into  the  cavity  of  the 
ventricle,  and  death  results  in  a  short  time.  Lesions  in  the 
region  of  distribution  of  the  posterior  external  optic  artery  are 
liable  to  implicate  the  fibres  of  the  external   and   posterior 


590  FOCAL  DISEASES,   ACCORDING  TO 

extremity  of  the  crusta  and  their  continuations  through  the 
internal  capsule.  The  path  of  least  resistance  to  the  passage 
of  hsemorrhage  from  the  vessel  appears  to  be  upwards  and 
inwards ;  and  as  the  internal  capsule  lies  below  and  to  the 
outside  of  the  thalamus,  its  fibres  are  never  injured  to  the 
same  extent  by  haemorrhages  from  this  vessel  as  they  are  in 
those  which  take  place  into  the  lenticular  nucleus.  Hemi- 
plegia is,  therefore,  not  a  prominent  feature  of  lesions  of  the 
optic  thalamus,  and  when  it  occurs  it  is  seldom  complete.  The 
sensory  peduncular  fibres,  and  the  optic  radiations  of  Gratiolet, 
are  very  liable  to  be  injured  by  lesions  in  the  region  of  dis- 
tribution of  the  posterior  external  optic  artery,  and  conse- 
quently complete  hemiansesthesia  with  implication  of  the 
special  senses  is  a  frequent  symptom.  When  the  lesion  occurs 
in  the  pulvinar,  the  external  geniculate  body  is  apt  to  be  impli- 
cated, and  then  bilateral  hemianopsia  of  the  opposite  side 
results.  When  the  lesion  is  situated  more  anteriorly  close  to 
the  internal  capsule,  the  fibres  of  the  pyramidal  tract  suffer  in- 
jury, and  hemiplegia  results.  The  hemiplegia  is  usually  asso- 
ciated with  a  certain  degree  of  hemiansesthesia,  and  after  a 
time  choreiform  movements  are  apt  to  become  established  in 
the  paralysed  limbs.  In  six  cases  of  post-hemiplegic  chorea 
collected  by  Raymond,  in  which  a  post-mortem  examination 
was  obtained,  the  lesion  was  situated  in  every  instance  in  the 
posterior  part  of  the  optic  thalamus,  and  involved  the  fibres  of 
the  internal  capsule;  and  in  two  cases  of  pre-hemiplegic  chorea 
reported  by  him,  the  lesion  was  situated  in  the  same  locality. 
In  a  case  of  pre-hemiplegic  chorea  reported  since  then  by 
Grasset,  several  lesions  were  found  in  different  regions  of  the 
hemispheres,  but  one  of  these  occupied  the  external  margin  of 
the  optic  thalamus  close  to  the  internal  capsule. 

The  lesions  which  have  been  found  to  give  rise  most  frequently 
to  hemichorea  are  yellow  cicatrices,  the  remains  of  old  haemor- 
rhages, or  softening  from  occlusion  of  the  posterior  external 
optic  artery,  although  choreiform  movements  have  occasionally 
been  observed  during  the  growth  of  tumours  in  this  region. 
It  is  evident,  therefore,  that  the  symptoms  depend,  not  upon 
the  nature  of  the  lesion,  but  on  its  localisation.  The  symptoms 
do  not  appear  to  depend  upon  lesion  of  the  optic  thalamus 


THE   LOCALISATION   OF   THE  LESION.  591 

itself,  inasmuch  as  they  are  uever  present,  unless  some  of  the 
fibres  of  the  sensory-peduncular  and  pyramidal  tracts  are 
injured,  nor  does  it  even  appear  to  be  caused  by  injury  of  the 
sensory  fibres,  since  hemiansesthesia  with  bilateral  hemianopsia 
may  be  present  without  being  associated  with  choreiform  move- 
ments. It  would  seem,  therefore,  that  injury  to  some  of  the 
fibres  which  lie  in  front  of  the  sensory  peduncular  tract  is  the 
cause  of  hemichorea.  That  some  of  the  fibres  of  the  pyramidal 
tract  are  always  injured  in  these  cases  can  scarcely  be  doubted, 
inasmuch  as  the  clonic  are  always  associated  with  tonic  spasms, 
and  exaggeration  of  the  tendon  reflexes,  the  latter  symptoms 
being  those  which  are  always  associated  with  disease  of  the 
pyramidal  tract.  Two  probable  explanations  of  the  clonic 
spasms  present  in  these  cases  suggest  themselves  to  my  mind. 
The  first  is  that  fibres  connecting  the  cerebrum  with  the  cere- 
bellum are  injured  by  these  lesions,  so  that  the  normal  propor- 
tion between  the  outgoing  discharges  which  regulate  the  tonic 
(cerebellar)  and  the  clonic  (cerebral)  actions  of  the  body  is  lost. 
The  second  is  that  the  injured  fibres  all  belong  to  the  pyramidal 
tract,  and  that  those  which  suffer  most  are  related  to  the  more 
fundamental  and  not  to  the  more  special  functions,  as  in  disease 
of  the  lenticular  nucleus.  We  have  seen  that  the  more  funda- 
mental actions  are  regulated  from  the  convolutions  near  the 
longitudinal  fissure,  while  the  more  special  movements  are 
regulated  from  the  convolutions  bordering  the  Sylvian  fissure  ; 
and  it  is  therefore  manifest  that  the  fibres  which  descend  in 
the  corona  radiata  from  the  former  will  pass  along  the  optic 
thalamus  side  of  the  internal  capsule,  while  those  which  descend 
from  the  latter  will  pass  on  the  side  of  the  capsule  next  the 
lenticular  nucleus.  The  effects  produced  by  destructive  pro- 
cesses in  any  structure  whatever  must  differ  greatly  according 
as  the  foundations  or  the  latest-formed  portions  are  the  first  to 
be  injured.  It  appears  to  me,  therefore,  that  partial  injury 
done  to  the  fundamental  motor  mechanism  while  the  acces- 
sory one  is  left  unaffected  would  be  very  likely  to  cause  the 
phenomena  of  hemichorea.  In  such  an  event  the  usual  tonic 
contractions  and  exaggerated  tendon  reflexes  would  result  from 
injury  of  the  pyramidal  tract,  while  the  apparatus  ef  the  more 
voluntary  and  special  actions,  although  still  uninjured,  would 


592  FOCAL    DISEASES,   ACCORDING  TO 

act  in  aa  irregular  manner  owing  to  the  damage  done  to  the 
fundamental  apparatus. 

The  lesions  found  in  cases  of  unilateral  athetosis,  although 
not  always  strictly  limited  to  the  region  of  the  posterior  external 
optic  artery,  have  often  been  in  its  vicinity.  In  three  cases 
of  athetosis  observed  by  Charcot  the  lesion  was  situated  in  the 
posterior  extremity  of  the  optic  thalamus  in  one,  the  posterior 
part  of  the  caudate  nucleus  in  a  second,  and  the  most  posterior 
part  of  the  corona  radiata  in  a  third.  The  lesions  of  all  these 
cases  were  situated  in  such  positions  that  the  same  system  of 
fibres  which  are  implicated  in  post-hemiplegic  chorea  would 
be  likely  to  suffer  damage,  and  consequently  athetosis  must 
generally  be  regarded  as  a  minor  degree  of  post-hemiplegic 
chorea.  In  a  case  observed  by  Landouzy  an  old  focus  of  soften- 
ing was  found  in  the  portion  of  the  lenticular  nucleus  which 
adjoins  the  internal  capsule.  In  another,  observed  by  Gnauck, 
the  co-existence  of  sensory  disturbances  in  the  region  of  distribu- 
tion of  the  fifth  nerve  on  the  side  opposite  to  the  spasmodic 
movements  rendered  it  probable  that  the  lesion  was  situated 
m  the  lateral  half  of  the  pons.  It  is,  therefore,  probable  that 
the  lesion  in  athetosis  may  occupy  different  positions  in  the 
vicinity  of  the  pyramidal  tract.  The  position  occupied  by  the 
lesion  in  all  cases  rendered  it  probable  that  the  fibres  of  the 
pyramidal  tract  are  never  completely  ruptured,  and  conse- 
quently there  are  no  descending  changes  in  the  cord  and  no 
muscular  rigidity  during  life.  The  fibres  of  the  tract  are,  how- 
ever, likely  to  have  suffered  partial  injury  by  being  involved  in 
a  cicatrix  or  other  morbid  change,  and  the  impulses  which  pass 
through  them  become  consequently  irregular. 

Direct  Cerebral  Paralysis. — Although  the  paralysis  of  the 
extremities  is  usually  situated  on  the  side  of  the  body  opposite 
the  lesion  in  the  brain,  it  is  occasionally  situated  on  the  same 
side,  and  is  then  called  direct  paralysis.  The  most  reasonable 
supposition  in  these  cases  is  that  the  pyramidal  tracts  do 
not  decussate  as  usual  in  the  medulla  oblongata.  The  usual 
method  of  crossing  is  that  from  91  to  97  per  cent  of  the  fibres 
cross  over  to  the  lateral  column  of  the  opposite  side  of  the  cord, 
while  from  9  to  3  per  cent  pass  downwards  in  the  columns  of 
Tiirck  of  the  same  side.     Flechsig,  however,  has  shown  that 


THE   LOCALISATION   OF   THE   LESION.  593 

the  proportion  of  fibres  which  decussate  is  very  variable,  and 
he  has  even  found  that  it  occasionally  fails  altogether.  It  is, 
therefore,  probable  that  the  decussation  may  fail  in  cases  of 
direct  paralysis,  although  this  has  not  yet  been  proved  by 
dissection. 

The  lesions  observed  in  the  spastic  hemiplegia  of  childhood 
scarcely  belong  to  the  category  at  present  under  consideration, 
inasmuch  as  they  primarily  involve  the  cortex  of  the  brain, 
while  the  internal  capsule  is  only  secondarily  implicated.  In 
infantile  hemiplegia  the  lesion  is  situated  in  the  convolutions 
of  the  motor  area  of  the  cortex.  The  primary  lesion,  consisting 
probably  of  a  local  encephalitis  sometimes  following  an  in- 
jury, local  softening,  or  haemorrhage,  gives  rise  to  extensive 
secondary  changes.  In  some  cases  a  large  loss  of  substance  has 
been  observed,  causing  various  deformities  of  the  skull  when  it 
occurs  in  early  life,  or  leading  to  hydrocephalus  in  order  to  fill 
up  the  vacant  space.  At  other  times  a  puckered  cicatrix  may  be 
found  at  the  seat  of  the  primary  lesion,  while  the  hemisphere 
has  undergone  a  diffused  consecutive  atrophy.  The  fibres  of 
the  pyramidal  tract  in  connection  with  the  diseased  focus 
undergo  descending  degeneration,  and  to  it  the  spastic  con- 
dition of  the  paralysed  extremities  is  either  directly  or  in- 
directly due.  Bilateral  athetosis  appears  also  to  be  due  to 
partial  atrophy  of  the  motor  area  of  the  cortex,  both  hemi- 
spheres being  probably  inplicated.  The  considerations  which 
favour  this  opinion  are  that  the  affection  is  either  congenital  or 
becomes  established  in  early  infancy,  that  it  is  associated  with 
some  degree  of  imbecility  or  idiocy,  and  that  there  are  no  sen- 
sory disturbances. 


MM 


594 


CHAPTEE   VII. 


(11.)  SPECIAL  CONSIDERATION  OF  FOCAL  DISEASES, 
ACCORDING  TO  THE  LOCALISATION  OF  THE  LESION 
(Continued). 


2.    CORTICAL   LESIONS. 

a.  Lesions  in  the  Area  of  the  Middle  Cerebral  Artery. 

(i.)   Monospasms  and  Unilateral  Convulsions. 

§  744.  Irritative  lesions  of  the  cortex  are  characterised  by 
unilateral  convulsions  or  monospasms.  Lesions  of  various  kinds 
may  cause  irritation  of  the  cortex,  the  most  common  of  these 
being  localised  meningo-encephalitis,  tubercle,  syphilitic  gum- 
mata  and  other  tumours,  cicatrices  of  wounds  and  spicula  of 
bone,  and  of  these  the  syphilitic  are  by  far  the  most  frequent 
lesions.  The  tissues  in  the  immediate  neighbourhood  of  the 
main  focus  of  disease  are  maintained  in  a  state  of  irritation,  and 
are  consequently  supplied  by  an  usually  large  quantity  of  blood. 
The  ganglion  cells  of  the  grey  substance  absorb  an  undue  supply 
of  nutriment,  so  that  they  discharge  themselves  in  a  sudden  and 
explosive  manner  (Hugh lings- Jackson).  But  we  have  already 
seen  that  explosive  discharges  of  nervous  energy  are  followed  by 
exhaustion  and  consequent  paralysis  of  the  muscles  implicated 
in  the  convulsion,  and  accordingly  unilateral  convulsions  are 
often  followed  by  temporary  paralysis  of  the  convulsed  limbs, 
it  must  be  remembered  that  an  irritative  lesion  is  frequently 
associated  with  a  destroying  one.  A  syphilitic  gumma,  for 
instance,  destroys  the  portion  of  the  cortex  in  which  it  is 
situated,  while  it  maintains  the  surrounding  tissues  in  a  state  of 
irritation.  It  is  not.j  therefore,  unusual  to  find  a  certain  degree 
of  permanent  paralysis  associated  with  unilateral  convulsions. 


FOCAL   DISEASES.  595 

Unilateral  convulsions  were  first  distinguished  clinically  and 
their  varieties  accurately  described  by  Bravais,  although  he  did 
not  recognise  their  pathological  significance.  Similar  observa- 
tions were  made  by  Bright  and  Wilks,  who  surmised  that 
these  convulsions  were  due  to  local  disease.  The  pathology 
of  these  spasmodic  affections  was  first  clearly  recognised  by 
Hughlings-Jackson,  and  it  was  in  explanation  of  these  convul- 
sions that  he  first  suggested  the  idea  of  the  existence  of  motor 
centres  in  the  cortex,  an  idea  which  has  been  so  fruitful  to 
pathology. 

In  some  cases  the  spasm  is  limited  to  one  limb  or  to  the 
side  of  the  head  (monospasm) ;  in  other  cases  it  begins  in  one 
limb  (protospasm),  and  extends  to  the  other  or  to  the  head,  to 
the  half  of  the  body,  or  the  convulsions  may  become  bilateral 
and  generalised.  Another  characteristic  of  these  convulsions  is 
that  they  are  either  not  attended  by  loss  of  consciousness  or 
the  convulsion  begins  before  the  patient  becomes  unconscious, 
so  that  he  is  afterwards  able  to  describe  a  motor  aura, 

§  745.  Varieties. — The  following  are  the  clinical  varieties 
of  unilateral  convulsions : — 

(a)  Crural  monospasm  or  protospasm,  in  which  the  spasms  are  either 
limited  to  the  leg,  or  begin  in  it,  the  arm  being  next  attacked  and  the  face 
last. 

(b)  Brachial  monospasm  or  protospasm,  in  which  the  spasms  are  either 
limited  to  the  arm,  or  begin  in  the  arm,  the  face  being  nexb  implicated  and 
the  leg  last. 

(c)  Facial  monospasm  or  protospasm,  in  which  the  spasms  are  either 
limited  to  the  side  of  the  face  or  begin  in  the  face,  the  arm  being  next 
implicated  and  the  leg  last, 

(a)  Crural  Monospasm  or  Protospasm. — There  are  not  many  uncom- 
plicated cases  on  record  in  which  the  spasms  were  limited  to  the  leg,  or 
invariably  began  in  the  leg,  and  in  which  a  post-mortem  examination  was 
obtained.  Ferrier  quotes  a  case  recorded  by  Broca  of  crural  monospasm 
caused  by  injury  to  the  left  side  of  the  skull,  which  was  cured  by 
trephining,  but  the  exact  position  on  the  brain  is  not  mentioned. 
Charcot  and  Pitres  quote  a  case  from  Griesinger  of  frequently  recurring 
spasm  of  the  leg  and  arm.  Numerous  cysticerci  were  found  in  the  brain, 
the  largest  of  which  occupied  the  superior  part  of  the  ascending  parietal 
convolution  of  the  opposite  side.  Several  small  cysts  were  found  on  the 
frontal  and  parietal  surface  of  the  same  hemisphere,  Hughlings-Jackson 
reports  a  case  in  which  the  fits  were  often  limited  to  the  leg,  and  always 
began  there.     The  leg  became  gradually  weaker  after  each  attack,  and 


596 


FOCAL   DISEASES,   ACCORDING  TO 


finally  became  permanently  paralysed.  A  tumour  was  found  at  the  upper 
and  posterior  part  of  the  left  frontal  lobe,  about  two  inches  in  diameter,  ex- 
tending from  the  posterior  extremities  of  the  first  and  second  frontal  con- 
volutions backwards  to  the  fissure  of  Rolando.  In  another  case  recorded 
by  the  same  author,  the  convulsions  began  in  the  left  great  toe,  and  were 
often  limited  to  the  left  leg.  A  syphilitic  lesion  was  found  at  the  upper 
part  of  the  ascending  parietal  convolution  and  over  several  of  the  adjacent 
convolutions  of  the  parietal  lobule.  Bourneville  describes  a  case  of  th.e 
hemiplegia  of  infancy,  in  which  the  convulsions  began  by  tremors  and 
twitching  in  the  left  or  paralysed  leg.     The  cortex  of  the  right  hemisphere 

Fig.  245. 


was  found  atrophied  in  front  of  the  fissure  of  Rolando  in  the  superior 
half  of  the  ascending  frontal,  the  posterior  extremities  of  the  first  and 
second  frontal  {Fig.  245),  and  the  whole  extent  of  the  paracentral  lobule. 
{h)  Brachial  Monospasm  or  Protospasm, — Several  cases  are  recorded  in 
which  the  spasm  is  either  limited  to  or  begins  in  the  arm.  Instances 
of  this  kind  have  been  recorded  by  Dr.  Hughlings- Jackson.  In  the  case 
of  one  man  who  suff"ered  from  repeated  convulsions  limited  to  the  right 
arm  with  subsequent  paralysis,  a  nodule  was  found  situated  at  the 
posterior  extremity  of  the  first  frontal  convolution  of  the  left  hemisphere. 
In  another  case,  in  which  the  spasms  were  almost  similar  to  those  observed 
in  the  last  case,  a  nodule  was  found  situated  at  the  posterior  extremity  of 
the  first  frontal  convolution  where  it  joins  the  ascending  frontal.  The 
spasm  in  this  case  began  in  the  shoulder  and  went  down  the  arm,  con- 
trary, Dr.  Jackson  thinks,  to  the  usual  order.  In  a  third  case  the  spasm 
invariably  began  in  the  left  thumb,  and  a  tumour  of  the  size  of  a  hazel-nut 
was  found  under  the  grey  matter  at  the  posterior  extremity  of  the  third 
frontal  convolution  of  the  right  hemisphere.  In  a  fourth  case  the  spasms 
began  in  the  right  arm,  and  occasionally  in  the  right  side  of  the  face,  and 
the  patient  had  suffered  from  a  transitory  attack  of  left  hemiplegia.  In  the 
left  hemisphere  adhesion  was  found  between  the  dura  mater  and  the  brain, 
over  "  the  lower  part  of  the  ascending  frontal  and  ascending  parietal  con- 
volutions, to  a  trifling  extent  to  the  hinder  part  of  the  third  frontal  and 


THE   LOCALISATION   OF   THE   LESION. 


597 


several  of  the  convolutions  of  the  upper  wall  of  the  fissure  of  Sylvius 
behind  the  ascending  parietal."  In  the  right  hemisphere,  the  side  opposite 
the  paralysis,  a  mass  was  found  behind  the  fissure  of  Rolando,  but  has 
no  bearing  upon  our  present  subject.  In  a  fifth  case  temporary  right 
hemiplegia  supervened  after  a  unilateral  convulsion.  Convulsions  recurred 
repeatedly,  beginning  in  the  little  finger  of  the  right  hand,  occasionally 
in  the  right  side  of  the  face,  and  always  followed  by  slow  and  hesitating 
speech.  A  syphilitic  tumour  of  considerable  size  was  found  in  the  cortex 
about  the  junction  of  the  frontal  and  parietal  lobes,  surrounded  by  an  area 
of  softening  in  the  posterior  extremities  of  the  frontal,  ascending  frontal 
and  ascending  parietal  convolutions,  and  partly  of  the  Island  of  Reil.  A 
case  of  partial  epilepsy  is  reported  by  Ballet  and  Lalesque  in  which  the 
spasms  began  in  the  right  hand.  Paresis  of  the  right  arm  supervened,  the 
right  side  of  the  face  and  tongue  being  also  implicated  to  a  slight  degree 
as  the  case  progressed.  Some  degree  of  embarrassment  of  speech  was  also 
present  before  death.  At  the  autopsy  three  small  hydatid  cysts  were 
found  in  the  cortex  of  the  left  hemisphere,  one  being  situated  about  the 
middle  of  the  ascending  frontal  convolution,  the  second  at  the  junction  of 
the  middle  and  lower  thirds  of  the  ascending  parietal  convolution,  and  the 
third  at  the  posterior  extremity  of  the  second  frontal  convolution. 

A  case  of  brachial  protospasm,  caused  by  syphilitic  disease,  has  been 
recorded  by  Dr.  Dreschfeld,  in  which  I  conducted  the  post-mortem  exami- 
nation, confirming  the  diagnosis  made  by  Dr.  Dreschfeld  during  life.  The 
attacks  began  "by  sudden  clenching  of  the  fist,  flexing  of  the  wrist,  and 

Fig.  246. 


pronation  of  the  forearm  of  the  left  side,  the  corresponding  angle  of  the 
mouth  being  at  the  same  time  drawn  downwards.  This  sudden  tonic  spasm 
lasted  for  several  seconds,  and  was  then  followed  by  a  few  clonic  spasms  of 
the  same  extremity  and  a  slight  tremor  of  the  arm,  the  patient  being  at  the 
same  time  agitated  and  pale,  but  perfectly  conscious."  The  dura  mater  was 
found  adherent  to  the  brain  on  the  right  side  over  the  greater  part  of  the 
ascending  parietal  convolution  and  the  supra-marginal  lobule  {Fig.  246). 


598  FOCAL   DISEASES,   ACCORDING  TO 

The  case  of  a  boy,  three  months  old,  is  reported  by  Mr.  Cullingworth,  who 
developed  cerebral  symptoms  somewhat  suddenly  nearly  four  months  sub- 
sequently to  an  injury  to  his  head.  The  symptoms  began  by  screaming 
and  elevation  of  temperature.  A  few  hours  later  it  was  observed  that  the 
left  arm  and  hand  were  flexed  and  rigid,  and  this  was  soon  followed  by 
conjugate  deviation  of  the  eyes  to  the  right.  The  dura  mater  was  found 
thickened  and  adherent  to  the  bone  over  a  small  area  of  the  right  hemi- 
sphere immediately  to  the  right  of  the  longitudinal  fissure.  The  cortex 
underlying  the  adhesions  was  reddened  and  softened,  the  softened  part 
involving  the  upper  portion  of  the  ascending  frontal  convolution.  A  layer 
of  pus  was  found  over  the  whole  surface  of  both  hemispheres  and  the 
greater  portion  of  the  cerebellum. 

Charcot  and  Lepine  describe  a  case  of  partial  epilepsy  beginning  in  the 
left  arm  in  which  after  death  a  hsemorrhagic  focus  was  found  situated  in 
the  posterior  part  of  the  first  right  frontal  convolution.  In  another  case 
of  partial  epilepsy  beginning  in  the  left  arm,  described  by  the  same 
authors,  an  old  focus  of  softening  was  found  between  the  first  and  second 
frontal  convolutions  of  the  right  hemisphere  where  they  adjoin  the 
ascending  frontal  convolution  ;  while  in  another  case  described  by  them, 
the  convulsions  began  in  the  right  arm,  and  a  small  focus  of  disease  was 
found  in  the  superior  part  of  the  ascending  parietal  convolution  of  the  left 
hemisphere.  A  case  is  described  by  Glicky,  in  which  the  convulsions 
began  in  the  left  arm,  but  subsequently  involved  the  left  half  of  the  body ; 
a  glioma  was  found  which  had  destroyed  the  two  ascending  central  convo- 
lutions and  the  paracentral  lobule  on  the  right  side.  Mahot  reports  a  case 
of  partial  convulsions  beginning  in  the  fingers  of  the  left  hand,  in  which  a 
tuberculous  mass  was  observed  imbedded  in  the  substance  of  the  right 
ascending  frontal  convolution  in  its  middle  third.  Berger  reports  the  case 
of  a  woman  who  suffered  from  convulsions  of  the  right  arm  with  subse- 
quent weakness  of  the  same,  the  convulsions  after  a  time  became  general, 
and  the  right  arm  was  completely  paralysed,  while  there  was  weakness  of 
the  muscles  of  the  leg  and  face.  A  sarcoma  growing  from  the  dura 
mater  had  penetrated  into  the  cortex  of  the  brain  over  the  left  ascending 
frontal  convolution,  opposite  the  posterior  extremity  of  the  second  frontal 
convolution.  Burresi  describes  a  case  of  partial  epilepsy  of  the  left  arm 
followed  by  paresis,  and  at  last  by  complete  paralysis ;  a  tuberculous  mass 
was  found  in  the  fissure  of  Rolando. 

(c)  Facial  MonosjMsm  or  Protospasm. — The  case  of  a  French  soldier  is 
described  by  Hitzig,  who,  two  months  after  a  bullet  wound  on  the  right 
side  of  the  head,  suffered  from  clonic  spasms  followed  by  paralysis  of  the 
left  side  of  the  face  and  tongue.  An  abscess  was  found  in  the  cortex  of 
the  right  hemisphere  situated  in  the  inferior  part  of  the  ascending  frontal 
on  a  level  with  the  third  frontal  convolution. 

Wernher  reports  a  case  in  which  there  were  convulsions  of  the  muscles 
of  the  face,  neck,  forearm,  and  of  the  extensors  and  flexors  of  the  fingers, 
all  on  the  right  side.     The  lesion  was  situated  in  the  cortex  of  the  left 


THE   LOCALISATION   OF   THE   LESION. 


599 


hemisphere  iu  the  inferior  part  of  the  ascending  frontal  convolution  near 
the  fissure  of  Sylvius. 

The  case  of  a  woman  is  described  by  Dr.  Bramwell,  who,  after  a  cranial 
injury  received  some  years  previously,  began  to  have  right-sided  convul- 
sions. The  convulsions  always  began  in  the  right  platysma,  and  were 
often  almost  entirely  confined  to  this  muscle.  A  spiculum  of  bone  was 
found  projecting  from  the  inner  table  of  the  skull,  and  causing  a  limited 
lesion  of  the  inferior  margin  of  the  ascending  parietal  convolution  {Fig. 
247). 

Fig.  247. 


Seeligmuller  describes  a  case  of  epileptiform  convulsions  of  the  right 
half  of  the  face,  followed  after  a^time  by  facial  paralysis.  At  a  some- 
what later  period  the  right  arm  became  convulsed,  and  afterwards  paralysed. 
A  sarcomatous  tumour  was  found  in  the  ascending  parietal  convolution, 
which  probably  began  to  grow  at  its  lower  extremity  and  progressed 
upwards. 

These  cases  tend  to  show  that  convulsions,  either  limited  to  or  begin- 
ning in  the  face,  are  caused  by  a  lesion  situated  in  the  inferior  part  of  the 
ascending  frontal  and  parietal  convolutions,  the  portion  which  adjoins  the 
fissure  of  Sylvius. 


(ii.)   Cortical  Paralyses  and  Monoplegia. 

§  746.  It  is  now  well  established  that  destructive  lesions  of 
the  cortex  of  the  brain  cause  permanent  paralyses.  Destroying 
lesions  of  the  motor  area  of  the  cortex  may  be  divided  into  (1) 
General  lesions,  extending  over  the  greater  part  of  the  area ; 
and  (2)  Partial  or  localised  lesions,  limited  to  small  portions 
of  it  (Ferrier). 

(1)  General  or  Extensive  Lesions  (Hemiplegia). — Extensive 


600 


FOCAL   DISEASES,   ACCORDING  TO 


lesions  of  the  cortex  give  rise  to  complete  hemiplegia,  similar 
in  all  essential  particulars  to  that  resulting  from  disease  of  the 
internal  capsule. 

A  case  of  complete  hemiplegia  of  the  right  side  of  six  years'  duration 
is  described  by  Lupine  in  which  there  was  total  destruction,  caused  by 
yellow  softening,  of  the  ascending  parietal  convolution  and  partial  de- 
struction of  the  Island  of  Reil,  ascending  frontal  convolution,  and  of  the 
anterior  part  of  the  superior  and  inferior  parietal  lobules  of  the  left 

Fig.  248. 


hemisphere  {Fig.  248).  Secondary  degeneration  was  traced  in  the  left  half 
of  the  pons  and  in  the  left  pyramid  of  the  medulla.  Duret  reports  a  case 
of  complete  right  hemiplegia  supervening  in  the  course  of  a  meningo- 
encephalitis. A  thick  fibro-purulent  exudation  occupied  the  three  frontal 
convolutions  of  both  sides,  but  it  extended  on  the  left  over  the  ascending 
frontal  and  ascending  parietal  convolutions,  the  lobule  of  the  pli  courbe, 
and  the  parietal  lobule. 

A  case  of  right  hemiplegia  with  aphasia  of  one  year's  duration,  accom- 
panied by  late  rigidity  of  the  paralysed  limbs,  is  reported  by  Charcot  and 
Pitres,  in  which  a  patch  of  yellow  softening  was  found,  involving  the  whole 
of  the  ascending  frontal,  the  base  of  the  third  frontal,  and  the  whole  of 
the  ascending  parietal  convolutions,  along  with  the  inferior  parietal  lobule 
and  the  two  posterior  digitations  of  the  Island  of  Reil  in  the  left  hemisphere. 
The  basal  ganglia  were  normal.  Secondary  degeneration  was  observed  in 
the  crus,  pons,  and  anterior  pyramid  on  the  same  side. 

A  case  is  quoted  by  Trousseau  which  occurred  in  the  dinique  of  Charcot, 
in  which  left  hemiplegia  existed  for  three  months ;  the  ascending 
frontal  and  third  frontal  convolutions,  and  Island  of  Reil  in  the  right 
hemisphere  were  found  softened.  Secondary  degeneration  was  traced  in 
the  crus,  pons,  and  pyramid  of  the  same  side  as  the  lesion,  and  on  the 


THE   LOCALISATION    OF   THE   LKSION. 


601 


opposite  side  of  the  spinal  cord  {Fig.  249).  Cases  of  this  kind  naight  be 
multiplied,  but  it  would  occupy  too  much  space  to  narrate  them.  The 
following  cases  are  examples  of  hemiplegia,  caused  by  lesions  of  the  cen- 
trum ovale. 

Fig.  249. 


A  case  of  right  hemiplegia,  with  late  rigidity  of  the  paralysed  limbs, 
is  related  by  Hodgson,  in  which  a  cavity  of  considerable  size  was  found  in 
the  centrum  ovale  of  the  left  hemisphere,  situated  between  the  anterior 
horn  of  the  lateral  ventricle  and  the  Island  of  Reil.  The  rest  of  the  brain 
was  normal. 

Dussaussay  describes  a  case,  quoted  by  Pitres,  of  right  hemiplegia 

Tig.  250, 


with  conjugate  deviation  of  the  eyes  to  the  left.  A  cavity  was  discovered 
in  the  centrum  ovale  of  the  left  hemisphere,  containing  dark,  coagulated 
blood  {Fig.  250).     The  cavity  was  limited  internally  by  the  grey  substance 


602 


FOCAL  DISEASES,  ACCORDING  TO 


of  the  paracentral  lobule,  superiorly  and  externally  by  the  grey  substance 
of  the  ascending  frontal  and  parietal  convolutions  ;  in  front  it  extended 
to  the  pra3-central  fissure,  and  behind  to  the  posterior  border  of  the  ascend- 
ing parietal  convolution ;  while  it  was  separated  inferiorly  from  the  corpus 
striatum  by  a  layer  of  white  substance  Ice.  in  thickness. 

Dr.  Ringrose  Atkins  has  recorded  a  case  of  right  hemiplegia  due  to 
embolism,  in  which,  in  addition  to  a  patch  of  softening  at  the  lower 
extremity  of  the  ascending  parietal  convolution  {Fig.  251),  there  was  a 

Tig.  251. 


focus  of  softening  two  inches  in  diameter  in  the  centrum  ovale,  extending 
from  a  point  '2\  inches  behind  the  apex  of  the  left  frontal  lobe  to  a  point 
3|-  inches  outward  to  the  apex  of  the  occipital  lobe.  The  basal  ganglia 
were  normal. 


(2)  Partial  or  Localised  Lesions  of  the  Motor  Area  of  the 
Cortex — Monoplegioe. 

(a)  Crural  Monoplegia. — The  recorded  cases  of  disease  of  the  cortex  in 
which  the  paralysis  was  limited  to  the  leg  are  not  numerous.  A  sufficient 
number  are  reported  to  render  the  existence  of  a  cortical  centre  for  the 
regulation  of  the  movements  of  the  lower  extremity  more  than  probable, 
even  from  clinical  evidence  alone  and  in  the  absence  of  the  more  elaborate 
proof  afforded  by  experiment  on  animals. 

Loffier  describes  the  case  of  a  Danish  corporal,  who  was  struck  by 
a  bullet  at  the  superior  and  posterior  extremity  of  the  left  parietal  bone, 
close  to  the  sagittal  suture.  The  right  leg  was  immediately  paralysed,  and 
the  right  arm  on  the  seventh  day  after  the  accident.  On  trephining, 
recovery  took  place,  the  arm  being  first  restored  and  then  the  leg.  In 
another  case  reported  by  the  same  author,  fracture  of  the  summit  of  the 
right  parietal  bone  was  followed  by  paralysis  of  the  left  leg. 

The  case  of  a  woman,  aged  76  years,  is  reported  by  Oudin,  in  which 
there  was  paralysis  with  contractures  and  arrest  of  development  of  the 


THE   LOCALISATION   OF   THE   LESION. 


603 


right  lower  extremities,  dating  from  the  age  of  nine  and  a  half  years,  and 
following  a  fall.  At  the  autopsy  the  median  parts  of  the  superior  surface 
of  the  hemispheres  were  found  to  present  a  remarkable  asymmetry.  The 
posterior  extremity  of  the  first  frontal  and  superior  extremity  of  the 
ascending  frontal  convolution  were  remarkably  atrophied  ou  the  left 
hemisphere,  while  the  corresponding  parts  of  the  right  hemisphere  were 
normal  and  of  comparatively  large  size.  The  superior  portions  of  the 
ascending  parietal  convolutions  were  atrophied  on  both  sides,  although 
the  atrophy  in  the  left  hemisphere  was  more  pronounced  than  in  the 
right.  The  anterior  extremity  of  the  superior  parietal  lobule  was  also 
involved  in  the  atrophy  on  the  left  side  {Fig.  252). 

Fig.  252. 


Dr.  Haddon,  of  Manchester,  records  a  case  in  which  paralysis  remained 
limited  to  the  left  leg  for  five  months,  but  after  a  time  the  left  arm  also 
became  paralysed.  After  death  a  tumour  three  inches  in  diameter  was 
found  connected  with  the  dura  mater,  situated  to  the  right  of  the  middle 
line,  compressing  the  subjacent  hemisphere,  and  destroying  the  upper  ex- 
tremities of  the  ascending  frontal  and  parietal  convolutions,  as  well  as 
the  postero-parietal  and  paracentral  lobules  {Figs.  253  and  254).  The  case 
of  a  man,  set.  40  years,  is  reported  by  Dr.  Ferrier,  in  which  the  symptoms 
of  general  tuberculosis  were  complicated  by  monoplegia  of  the  left  lower 
extremity.  The  paralysis  was  strictly  limited  for  four  days  to  the  left  leg, 
but  subsequently  extended  to  the  left  arm.  The  patient  died  a  month 
subsequently  to  the  appearance  of  the  paralytic  symptoms,  and  at  the 


604 


FOCAL   DISEASES,  ACCORDING  TO 


autopsy  the  pia  mater  over  the  upper  margin  and  internal  aspect  of  the 
right  hemisphere  on  both  sides  of  the  fissure  of  Rolando  was  merged  into 
a  caseous  mass,  which  could  not  be  removed  without  tearing  the  cortical 
substance.     The  lesion  occupied  the  quadrilateral  lobule  on  the  internal 


Fig.  253. 


aspect  of  the  hemisphere,  and  the  upper  extremities  of  the  ascending 
parietal  and  frontal  convolutions  on  its  superior  and  external  aspect,  the 
portion  of  the  cortex  implicated  corresponding  to  the  areas  marked  1  and  2 
on  the  monkey's  brain  {Figs.  230  and  231). 


Fig.  254. 


THE  LOCALISATION    OF   THE   LESION. 


605 


(b)  Brachio-crural  Monoplegia. — Paralysis  of  the  leg  and  arm  are 
frequently  associated  in  disease  of  the  cortex.  Charcot  and  Pitres  de- 
scribe a  case  of  paralysis  with  rigidity  of  the  limbs  of  three  years' 
duration,  in  which  a  patch  of  softening  was  found  at  the  upper  extremity 
of  the  fissure  of  Rolando  on  the  convex  surface  of  the  right  hemisphere 

Fig.  255. 


{Fig.  255).  Hughlings- Jackson  reports  a  case  of  paralysis  of  the  left  ex- 
tremities caused  by  a  glioma  situated  in  the  superior  part  of  the  fissure 
of  Rolando,  and  comprising  the  ascending  parietal  convolution  and  the 

Fig.  256. 


parietal  lobule.  A  larger  number  of  examples  of  brachio-crural  monoplegia 
resulting  from  cortical  disease  might  be  quoted,  but  these  must  suffice. 
Pitres  describes  a  case  of  paralysis  with  unilateral  convulsions  of  the 


606 


FOCAL  DISEASES,   ACCORDING  TO 


left  extremities  in  which  a  focus  of  softening  was  found,  not  in  the  cortex, 
but  in  the  centrum  ovale,  immediately  beneath  the  posterior  extremity 
of  the  first  frontal  convolution  {Fig.  256,  L),  and  extending  backwards 
underneath  the  superior  parietal  lobule. 

(c)  Brachial  Monoplegia. — A  case  of  paralysis  of  the  left  arm  is  de- 
scribed by  Pierret  in  which  a  centre  of  softening  was  found  in  the  cortex 
of  the  right  hemisphere  at  the  point  where  the  second  frontal  joins  the 

Fig.  257. 


ascending  frontal  convolution  {Fig.  257).  Boyer  records  a  case  in  which  the 
arm  and  leg  became  suddenly  paralysed,  the  paralysis  of  the  arm  alone 
remaining  permanent.  Death  took  place  five  years  subsequently  to  this 
attack,  and  a  patch  of  atrophy  was  found  on  the  right  hemisphere  in  the 
ascending  frontal  and  parietal  convolutions,  with  an  extension  of  the 
lesion  to  the  temporo-sphenoidal  lobe. 

A  case  of  paralysis  of  the  right  hand  and  arm  is  reported  by  Ringrose 
Atkins  supervening  a  few  days  before  death  in  a  patient  suffering  from 
general  paralysis.  The  cortex  was  softened  in  the  middle  of  the  ascending 
frontal  and  parietal  convolutions,  the  lesion  also  extending  backwards 
along  the  anterior  edge  of  the  supra-marginal  gyrus  as  shown  in  Fig.  258. 

Fig.  258. 


THE  LOCALISATION    OF   THE  LESION. 


607 


Decaisne  has  collected  a  large  number  of  cases  of  brachial  monoplegiae, 
but  it  would  occupy  too  much  space  to  quote  more  cases  at  present. 

It  may  be  observed  in  passing  that  the  central  convolutions  of  the  oppo- 
site hemisphere  have  been  found  atrophied  in  cases  of  long-standing 
amputation  (Chuquet,  Boyer).  The  results  obtained  have  not,  however, 
been  very  definite.  Dr.  Gowers  found  in  a  case  of  congenital  absence  of 
the  left  hand  the  middle  part  of  the  ascending  parietal  convolutions  in  the 
right  hemisphere  distinctly  smaller  than  the  corresponding  convolutions 
in  the  left,  and  a  somewhat  similar  case  has  been  recorded  by  Bastian. 

(d)  Brachio-facial  Monoplegia. — Paralysis  of  the  face  and  arm  are  not 
uncommonly  associated.  When  the  left  hemisphere  is  the  seat  of  the 
lesion,  these  cases  are  usually  associated  with  aphasia.  Dieulafoy  records 
a  case  of  paralysis  of  the  face  and  arm  in  which  the  autopsy  revealed  a 
hsemorrhagic  focus,  the  size  of  a  nut,  situated  in  the  ascending  frontal  con- 
volution on  a  line  with  the  third  frontal  convolution.  Troisier  mentions  a 
case  of  paralysis  of  the  arm  and  face  in  which  tubercular  granulations 
and  congestion  were  found  immediately 
posterior  to  the  third  frontal  convolu- 
tion. Landouzy  describes  a  case  of  slight 
paralysis  of  the  inferior  facial  muscles  and  of 
the  arm  caused  by  a  spot  of  tubercular 
meningitis  occupying  the  inferior  part  of 
the  fissure  of  Rolando,  and  the  inferior  half 
of  the  two  ascending  convolutions.  Pitres 
quotes  from  Anton  Frey  a  case  in  which  there 
was  paresis  of  the  left  arm  and  of  the  left 
side  of  the  face;  the  autopsy  showed  a  focus 
of  softening  in  the  medullary  fibres  at  the 
junction  of  the  middle  frontal  with  the 
ascending  frontal  convolutions  {Fig.  259). 

(e)  Facial  Monoplegia. — Facial  paralysis  of  cerebral  origin  is  generally 
complicated  by  aphasia  or  paralysis  of  the  arm,  but  a  few  uncomplicated 
cases  of  facial  paralysis  from  diseases  of  the  cortex  have  been  observed. 


Tig    259. 


Fig.  260. 


G08 


FOCAL   DISEASES,   ACCORDING  TO 


Charcot  and  Pifcres  describe  a  case  of  apoplexy  followed  by  left  hemi- 
plegia and  rigidity  of  the  limbs.  The  rigidity  disappeared  after  a  time  and 
the  paralysis  became  limited  to  the  lower  facial  muscles.  An  extensive 
area  of  softening  was  found  in  the  cortex  of  the  right  hemisphere,  invading 
the  third  frontal,  the  lower  extremities  of  the  ascending  frontal  and 
parietal  convolutions,  and  a  large  extent  of  the  parietal  and  temporo- 
sphenoidal  lobes  of  the  Island  of  Keil  {Fig.  260).  Although  the  cortical 
lesion  in  this  case  was  so  extensive,  it  will  be  seen  that  disease  of  the  inferior 
extremities  of  the  ascending  convolutions  was  the  important  lesion  so  far 
as  the  motor  area  is  concerned.  Hitzig  relates  the  case  of  a  soldier  who 
received  a  bullet-wound  on  the  right  side  of  the  head  and  became  affected 
two  months  subsequently  with  clonic  spasms  in  the  left  side  of  the  face, 
followed  by  paralysis  of  those  muscles  and  of  the  left  half  of  the  tongue. 
After  death  an  abscess  was  found  in  the  ascending  frontal  convolution 
between  the  prse-central  fissure  and  the  fissure  of  Rolando,  corresponding 
to  the  seat  of  injury  {Fig.  261). 

Fig.  261. 


A  case  of  left  hemiplegia  is  reported  by  Dr.  Gowers  in  which  gradual 
recovery  took  place,  with  the  exception  of  marked  paralysis  of  the  inferior 
facial  muscles.  At  the  autopsy  a  hsemorrhagic  extravasation  was  found 
in  and  beneath  the  upper  half  of  the  prse-central  sulcus  which  had  passed 
into  the  substance  of  the  adjoining  convolutions,  consisting  of  the  posterior 
extremities  of  the  middle  and  superior  frontal  and  corresponding  part  of 
the  ascending  frontal  of  the  right  hemisphere.  A  large  number  of  cases 
might  be  cited  in  which  right  facial  paralysis  existed,  associated  with 
aphasia,  and  in  which  the  lesion  was  situated  at  the  junction  of  the  third 
frontal  with  the  ascending  frontal  convolution  of  the  left  hemisphere.  The 
case  of  a  woman,  aged  71  years,  is  reported  by  Ballet,  who  had  a  slight 
attack  of  apoplexy  without  loss  of  consciousness.  The  permanent  symptoms 
consisted  of  paralysis  of  the  left  half  of  the  face  and  of  the  tongue.  There 
was  also  slight  feebleness  of  the  left  upper  extremities,  but  the  lower  was 
unaffected.   There  were  no  sensory  disturbances.    Towards  the  evening  of 


THE  LOCALISATION   OF   THE  LESION. 


609 


the  same  day  the  head  and  neck  became  deviated  to  the  right  and  the 
paralysis  of  the  left  arm  became  more  marked.  Death  took  place  from 
coma  four  days  subsequently  to  the  beginning  of  the  attack,  and  at  the 
autopsy  a  hsemorrhagic  focus,  of  the  size  of  a  large  nut,  was  found  in 
the  inferior  part  of  the  ascending  frontal  convolution  {Fig.  262).  The  in- 
ferior frontal  and  inferior  parietal  fasciculi  of  the  white  tissue  were  partially 
destroyed,  but  the  basal  ganglia  were  normaL 


Fig.  262. 


(/)  Unilateral  Oculo-motor  Monoplegia. — It  has  already  been  mentioned 
that  conjugate  deviation  of  the  eyes  and  rotation  of  the  head  and  neck  are 
frequent  symptoms  both  of  convulsions  and  of  hemiplegia,  and  that  the 
deviation  in  the  former  is  directed  away  from,  and  in  the  latter  towards 
the  hemisphere  in  which  the  lesion  is  situated.  In  the  brain  of  the 
monkey,  Ferrier  localises  a  centre  {Fig.  232, 12)  in  the  posterior  extremity 
of  the  second  frontal  extremity,  irritation  of  which  causes  elevation  of  the 
eyelids,  dilatation  of  the  pupils,  conjugate  deviation  of  the  eyes,  and 
turning  of  the  head  to  the  opposite  side ;  while,  on  the  other  hand, 
extensive  movements  of  the  eyeballs,  along  with  associated  movements  of 
the  head  and  neck,  result  from  irritation  of  the  supra-marginal  and 
angular  gyri  (Fig.  232,  13, 13'). 

A  case  is  reported  by  Chouppe  which  appears  to  show  that  the  centre 
for  the  production  of  conjugate  deviation  of  the  eyes  and  rotation  of  the 
head  and  neck  is  situated  in  the  posterior  extremity  of  the  second  frontal 
convolution.  The  case  as  quoted  by  Landouzy  was  that  of  a  young 
man,  19  years  of  age,  who  presented  the  ordinary  symptoms  of  tubercular 
meningitis,  the  most  striking  being  a  rotation  of  the  head  and  eyes  to  the 
right  without  any  other  paralysis.  After  death  a  superficial  focus  of 
disease,  of  the  size  of  a  franc  piece,  was  found  on  the  posterior  extremity 
of  the  middle  frontal  convolution  in  the  left  hemisphere.  Other  lesions 
were  found  in  the  superior  and  lateral  part  of  the  sphenoidal  lobe  of  the 
right  hemisphere.  Landouzy  thinks  that  the  deviation  of  the  eyes  was 
caused  by  an  irritative  lesion  of  the  posterior  extremity  of  the  second 
frontal  convolution,  but  it  must  be  remembered  that  the  lesion  in  the 
N  N 


610 


FOCAL   DISEASES,   ACCORDING  TO 


superior  part  of  the  sphenoidal  lobe  was  close  to  the  angular  gyrus,  and  it 
is  probable  that  the  deviation  was  due  to  a  destroying  lesion  in  this  area. 

The  case  of  a  child,  aged  five  months,  is  mentioned  by  Farrier,  on  the 
authority  of  Dr.  Carroll,  of  New  York,  in  which  a  fracture  of  the  skull 
was  produced  by  a  fall.  When  Dr.  Carroll  saw  the  patient,  the  head  was 
rotated  to  the  right,  its  range  of  motion  never  extending  to  the  left  of 
the  middle  line ;  the  eyes,  when  at  rest,  were  turned  to  the  right,  but  could 
be  voluntarily  moved  almost  to  the  middle  line ;  pupils,  perhaps,  a  little 
dilated,  but  responsive  to  light ;  upper  lids  elevated.  There  was  a  fracture 
in  the  right  parietal  region,  and  a  linear  fracture  could  be  detected  in  the 
parietal  bone,  about  midway  between  the  squamous  and  sagittal  sutures, 
and  intersecting  a  vertical  line  drawn  upwards  from  the  auditory  meatus. 
The  position  of  the  fracture  was,  as  pointed  out  by  Ferrier,  such  as  might 
coincide  with  injury  of  the  posterior  extremity  of  the  second  frontal  con- 
volution, the  lesion  being  doubtless  of  a  paralytic  nature.  It  must,  how- 
ever, be  admitted  that  these  two  cases  are  not  of  themselves  sufficient  to 
prove  the  existence  of  a  centre  for  the  rotation  of  the  eyes  situated  in  the 
middle  frontal  convolution. 

Strong  evidence  has  indeed  been  recently  brought  forward  by  Grasset 
to  show  that  when  conjugate  deviation  of  the  eyes  is  caused  by  disease  of 
the  cortex,  the  lesion  is  situated  in  the  supra-marginal  and  angular  gyri. 
He  reports  a  case  of  left  hemiplegia  with  conjugate  deviation  directed  to 
the  right,  in  which  the  lesion  consisted  of  disease  of  the  pli  courbe  of  the 
right  hemisphere  {Fig.  263).     Liouville  describes  a  case  of  right  unilateral 

Fig.  263. 


convulsions  in  which  the  head  was  strongly  turned  towards  the  right. 
The  lesion,  which  consisted  of  tubercular  meningitis,  was  situated  on 
both  sides  of  the  horizontal  limb  of  the  fissure  of  Sylvius  on  the  left 
hemisphere. 

Sergiu  reports  a  case  of  left  hemiplegia  with  contracture  of  the  muscles 
of  the  right  side  (probably  paralysis  of  the  muscles  of  the  left  side)  of  the 
neck.     The  lesion  consisted  of  a  meningo-encephalitis  in  the  right  middle 


THE  LOCALISATION   OF   THE   LESION.  611 

lobe  at  the  level  of  the  superior  part  of  the  fissure  of  Sylvius.  Charcot 
and  Pitres  mention  a  case  reported  by  Samt,  in  which  there  was  right 
hemiplegia,  while  the  head  and  eyes  were  deviated  to  the  left.  A  focus 
of  softening  was  found  situated  upon  the  parietal  lobe,  not  quite  reaching 
the  ascending  frontal  convolution  in  front,  bounded  posteriorly  and  in- 
feriorly  by  the  posterior  extremity  of  the  parallel  fissure,  and  passing 
beyond  the  interparietal  fissure  superiorly,  but  not  quite  reaching  to  the 
great  longitudinal  fissure.  These  cases,  although  many  more  might  be 
added,  will  sufl&ce  to  show  the  importance,  with  regard  to  conjugate 
deviation  of  the  eyes,  of  the  convolutions  which  border  the  posterior 
extremities  of  the  Sylvian  and  parallel  fissures. 

Many  cases  are  recorded  in  which  conjugate  deviation  of  the  eyes  was 
caused  by  disease  of  the  centrum  ovale,  and  in  these  the  lesion  was,  as  a 
rule,  situated  between  the  internal  capsule  and  the  supra-marginal  and 
angular  gyri.  Provost  reports  a  case  of  right  hemiplegia  with  rotation 
of  the  head  and  eyes  to  the  left.  A  haemorrhagic  focus  was  found  in  the 
posterior  part  of  the  parietal  lobe  of  the  left  hemisphere.  In  another  case 
reported  by  the  same  author  right  hemiplegia,  with  rotation  of  the  head 
and  eyes  to  the  left,  was  caused  by  a  sarcoma,  of  the  size  of  a  pigeon's 
egg,  situated  in  the  centrum  ovale  behind  the  fissure  of  Rolando,  and 
along  the  longitudinal  fissure. 

It  would  appear  that  disease  in  the  neighbourhood  of  the  angular  gyrus 
and  supra-marginal  lobule  produces  at  times  paralysis  of  the  levator  pal- 
pebrae  superioris  of  the  opposite  side,  without  the  other  muscles  supplied 
by  the  third  nerve  being  implicated  (Landouzy). 

Lesions  may  occur  in  the  cortex  of  the  brain  in  the  area  of  distribution 
of  the  middle  cerebral  artery  without  being  attended  by  paralysis.  Boyer 
maintains  that  there  are  two  "  neutral  "  zones  in  the  area,  the  one  occu- 
pying the  superior  parietal  lobule,  and  the  other  the  anterior  part  of  the 
praecuneus  and  a  part  of  the  gyrus  fornicatus,  A  case  is  reported  by  Dr. 
Ringrose  Atkins,  in  which  there  was  a  superficial  erosion  of  the  cortex  on 
the  postero-parietal  lobule  of  the  left  hemisphere  without  motor  disturb- 
ance having  been  present  during  life.  I  would  suggest  that  the  neutral 
zones  of  Boyer  are  associated  with  centrifugal  fibres  connecting  the  cortex 
of  the  brain  with  the  cerebellum.  Other  cases  are  recorded  in  which  the 
cortical  motor  centre  of  the  leg  was  found  diseased  at  the  autopsy,  yet  in 
which  the  leg  on  the  opposite  side  either  had  never  been  paralysed  or  had 
recovered.  It  is  probable  that  in  such  cases  the  movements  of  both  lower 
extremities  were  regulated  from  one  hemisphere,  the  one  on  the  side 
opposite  the  lesion  receiving  its  impulses  through  commissural  fibres  in 
the  spinal  cord. 

The  motor  area  of  the  cortex  may  be  compressed  by  very  large  tumours 
without  paralysis  being  produced.  In  the  Pathological  Museum  of  the 
Owens  College  there  is  a  preparation,  presented  by  Mr.  Windsor  in  1877, 
of  a  sarcomatous  tumour,  about  the  size  of  the  closed  fist,  which  grew 
from  the  dura  mater  over  the  vertex,  and  near  to  the  falx  cerebri.     The 


612  FOCAL   DISEASES,  ACCORDING  TO 

underlying  hemisphere  was  compressed  and  flattened,  the  motor  area  of 
the  cortex  being  involved,  but  the  patient  had  no  paralytic  symptoms 
during  life.  Two  cases  of  a  more  or  less  similar  kind  have  been  recently 
described  by  Pitres. 

Sensory  Disturbances. — It  has  been  maintained  by  Tripier  that  lesions 
of  the  cortical  motor  area  of  the  brain  are  sometimes  attended  by 
hemiansesthesaa  as  well  as  paralysis  of  the  opposite  side  of  the  body, 
tactile  sensibility  being  specially  affected.  He  adduces  in  favour  of  this 
opinion  some  experimental  evidence,  and  reports  of  seven  clinical  cases 
in  which  more  or  less  of  hemiplegia  was  associated  with  hemianaesthesia, 
the  lesion  in  all  of  them  being  found  limited  to  the  motor  area  of  the 
cortex  of  the  hemisphere  opposite  to  the  side  affected.  But  hemi- 
ansesthesia  so  frequently  results  from  functional  disturbances  of  the 
brain  that  it  would  be  somewhat  hazardous  to  conclude  from  these  cases 
alone  that  the  lesion  of  the  motor  area  of  the  cortex  was  the  cause  of  the 
loss  of  sensibility.  Several  cases  are  collected  by  Nothnagel  to  show 
that  diminution  of  the  muscular  sense  is  not  unfrequently  associated 
with  motor  paralysis  from  cortical  disease.  He  thinks  that  the  cortical 
centres  of  the  muscular  sense  lie  near  to,  although  they  are  not  identical 
with,  the  motor  centres. 

Vaso-motor  and  trophic  disturbances,  consisting  of  elevation  of  the 
temperature  of  the  paralysed  limbs  and  acute  bed-sore,  have  been 
observed  in  cases  of  disease  of  the  cortex  of  the  brain,  but  they  do  not 
possess  any  value  as  localising  symptoms. 

(iii.)  Affections  of  Speech  feom  Coeiical  Disease. 
§  747.  The  disorders  of  speech  which  are  liable  to  occur  in 
cortical  disease  constitute  one  of  the  most  complicated  problems 
of  neurology;  and  before  proceeding  further,  it  is  desirable  to 
limit  our  subject  so  as  to  separate  disorders  of  speech  due  to 
disease  of  the  cortex  of  the  brain  from  other  affections  of  the 
nervous  system  that  may  resemble  them.  Language,  taken  in 
its  widest  sense,  consists  of  the  various  means  by  which  animals 
indicate  mental  states  to  one  another.  Mental  states  may  be, 
as  we  have  seen,  divided  into  feelings,  cognitions,  and  volitions. 
In  one  sense  language  may  be  said  very  often,  if  not  always,  to 
indicate  volitions ;  but  inasmuch  as  volitions  are  practically 
always  determined  by  what  are  called  motives,  or  in  other  words 
by  the  feelings  and  cognitions,  the  language  of  volitions  merges 
itself  into  that  of  the  other  two  mental  states.  Language  may 
therefore  be  divided  into  that  of  the  feelings  or  emotional 
language,  and  that  of  the  cognitions  or  intellectual  language 
or  speech. 


THE   LOCALISATION   OF   THE   LESION.  613 

But  the  division  between  the  language  of  the  emotions  and 
speech  is  by  no  means  clear  and  trenchant.  When  a  man 
delivers  an  oration,  for  instance,  only  a  small  part  of  what  he 
utters  is  speech.  All  the  variations  of  tone,  the  melodious 
voice,  the  graces  of  attitude  and  gesture,  the  charm  of  elegant 
and  rhythmical  language,  and  the  thousand  other  ways  by  which 
a  great  orator  knows  how  to  sway  and  influence  his  audience, 
belong  to  emotional  and  not  to  intellectual  language.  Similar 
remarks  apply  to  written  language.  The  pleasure  we  derive 
from  looking  at  a  clearly-printed  volume,  and  especially  from 
looking  at  an  illuminated  text,  the  pleasure  derived  from 
looking  at  a  well-executed  picture  rather  than  at  a  diagram, 
the  methods,  as  accent,  italics,  and  notes  of  exclamation, 
by  which  inflection  and  emphasis  and  wonder  are  indicated; 
the  rhythm  of  metrical  language,  and  the  diction  and  imagery 
of  poetry  belong  to  emotional  language.  The  languages  of 
emotional  and  of  intellectual  gesture  are  also  by  no  means  readily 
separated.  The  gestures  of  those  who  retain  the  full  use  of 
spoken  and  written  language  are  in  great  part  indicative  of  the 
feelings,  but  that  gesture  can  be  made  subservient  to  intel- 
lectual expression  is  shown  by  the  importance  it  assumes  in  the 
intellectual  training  of  the  deaf  and  dumb. 

Language  is  the  instrument  of  the  social  state,  and  that  it 
may  be  the  means  of  intercommunication  between  animals  it 
possesses  to  each  a  subjective  and  an  objective  value,  or  fulfils 
an  impressive  and  expressive  function.  Each  individual  of  a 
social  community,  in  order  to  become  an  effective  member,  must 
be  able  to  feel  or  comprehend  the  mental  states  of  the  others 
from  watching  their  gestures  and  listening  to  their  various 
vocalisations,  and  must  also  be  able  by  his  gestures  and  vocalisa- 
tions to  render  his  own  mental  states  intelligible  to  the  others. 

The  subjective  or  impressive  function  of  language,  or  rather 
of  speech,  with  which  we  are  here  more  immediately  concerned, 
may  be  subdivided  into  receptive  and  regulative  functions. 

The  receptive  department  is  represented  structurally  by  the 
various  peripheral  sense-organs  and  the  centripetal  fibres,  or  cells 
and  fibres,  which  conduct  impressions  made  upon  the  former  to 
the  cortex.  Complete  loss  of  speech  from  disease  of  the  receptive 
apparatus  is  unknown. 


614!  FOCAL   DISEASES,   ACCORDING  TO 

The  vocal  speech  of  a  person  born  blind  is  almost  entirely 
unaffected  either  in  its  subjective  or  objective  aspects,  while 
the  patient  may,  by  the  device  of  raised  letters,  be  taught  to 
understand  written  language.  The  deaf  mute  is  taught  both  to 
understand  and  to  give  expression  to  a  complicated  speech  by 
gesture ;  and  in  recent  times  such  patients  have  been  taught  to 
use  their  vocal  organs  for  expression  in  speech,  while  they  are 
made  to  understand  the  vocal  speech  of  others  by  closely  ob- 
serving the  movements  of  the  muscles  of  articulation. 

The  remarkable  case  of  Laura  Bridgeman,  who  became  blind  and  deaf 
in  her  second  year,  while  her  sense  of  smell  and  taste  were  also  very 
deficient,  shows  how  much  careful  training  may  do  in  developing  language 
and  thought  through  the  sense  of  touch.  This  girl  was  taught  by  Dr. 
Howe,  of  Boston,  who  affixed  on  a  number  of  common  objects  labels  on 
which  the  name  of  the  article  was  written  in  raised  characters.  After  she 
had  learnt  to  associate  each  label  with  its  object,  a  number  of  separate 
labels  were  put  in  her  hand,  and  she  was  then  encouraged  to  place  each 
label  on  its  corresponding  object.  After  a  time  the  separate  letters  were 
placed  in  her  hand,  and  she  was  then  taught  to  put  them  together  so  as  to 
form  the  names  of  common  objects.  "  Up  to  this,"  says  Dr.  Howe,  "  the 
proceeding  was  only  a  mechanical  one,  and  the  result  was  about  as  great 
as  if  one  had  taught  a  number  of  tricks  to  a  clever  dog.  The  poor  child 
had  sat  there  in  mute  astonishment,  and  patiently  imitated  everything 
that  was  performed  before  her.  But  now  the  matter  seemed  to  dawn  upon 
her  in  its  true  light,  her  understanding  began  to  esercise  itself,  she  noticed 
that  she  now  possessed  the  means  of  arranging  for  herself  symbols  of  some- 
thing that  lay  before  her  mind,  and  of  showing  this  to  another  mind ; 
immediately  her  countenance  beamed  with  human  reason ;  she  could  no 
longer  be  compared  to  a  parrot  or  dog ;  the  immortal  intellect  now  seized 
greedily  upon  this  new  bond  of  union  with  other  intellects !  I  could  almost 
point  out  the  moment  at  which  this  truth  dawned  upon  her  and  poured 
light  over  her  whole  face," 

The  structural  counterpart  of  the  regulative  function  consists 
of  that  part  of  the  cortex  of  the  brain  in  which  the  centripetal 
impulses  are  reduced  to  such  order  as  is  necessary  to  render 
them  the  correlatives  of  the  cognitions.  Now,  the  cognitions, 
as  we  have  seen,  express  the  relations  between  our  feelings,  and 
all  cognitions  must  be  expressed  by  propositions.  The  mode  of 
expression  may  not  always  assume  a  distinct  propositional  form, 
but  it  must  at  least  possess  a  propositional  value  if  it  convey 
distinct  knowledge.  If  I  repeat  the  word  "  orange "  in  the 
hearing  of  another,  it  may,  or  may  not,  convey  to  him  distinct 


THE   LOCALISATION   OF  THE  LESION.  615 

information  ;  but  if  any  information  be  imparted,  the  word 
must  convey  to  the  listener  the  idea  that  the  object  named 
"orange"  belongs  to  a  class  of  objects  already  known  to  him 
under  that  name,  and  the  word  in  this  sense  possesses  the  value 
of  a  distinct  proposition.  If  the  listener  has  never  had  any 
experience  of  the  object  named  "orange,"  it  is  clear  that  the 
utterance  of  the  name  will  convey  no  meaning ;  but  if  he  has 
had  experience  of  other  fruits  and  of  colours,  distinct  information 
may  be  conveyed  to  him  with  regard  to  the  object  by  saying 
"  an  orange  is  a  yellow  fruit."  The  listener  will  be  able  to 
associate  the  general  properties  of  fruit  and  a  distinct  colour 
with  the  word  in  future,  but  the  information  has  been  im- 
parted by  means  of  a  formal  proposition.  The  activity  of  the 
regulative  cortical  centres  of  speech  have  for  their  functional 
correlative  the  arrangement  of  the  presentative  and  represen- 
tative cognitions  into  the  form  of  distinct  mental  propositions. 

The  objective  or  expressive  function  of  speech  may  be  sub- 
divided into  emissive  and  executive  departments. 

The  emissive  department  is  represented  structurally  by  that 
organisation  in  the  cortex  of  the  brain  in  which  the  regulative 
impulses  are  finally  co-ordinated  before  being  conducted  to  the 
executive  department. 

The  executive  department  is  represented  structurally  by 
groups  of  nerve  cells  in  the  central  grey  tube,  and  by  the 
nerves  and  muscles  concerned  in  vocalisation,  articulation, 
the  manual  operations  of  writing,  and  various  gestures.  Com- 
plete loss  of  speech  from  disease  in  the  executive  structure 
is  most  unusual.  The  patient,  for  instance,  may  lose  his 
voice  in  different  diseases  of  the  larynx,  but  he  can  still  arti- 
culate; he  may  lose  both  voice  and  articulation  in  bulbar 
paralysis,  but  is  generally  able  to  make  known  his  wants  in 
writing,  and  •  when  unable  to  write  from  want  of  previous 
education  he  can  make  his  ordinary  wants  known  by  gesture. 

Our  further  remarks  must  be  limited  to  the  derangements  of 
speech  caused  by  disease  of  the  cortex  of  the  brain.  These 
consist  of  disorders  of  the  regulative  department  of  the  im- 
pressive function,  and  of  the  emissive  department  of  the 
expressive  function;  and  as  the  latter  is  probably  the  simpler 
of  the  two,  we  shall  deal  with  it  first. 


616  FOCAL  DISEASES,  ACCORDING   TO 

§  748.  (<x)  Loss  or  Impairment  of  the  Emissive  department 
of  the  Expressive  faculty  of  Speech  while  the  Impressive 
faculty  is  unaffected.  (Ataxic  Aphasia — Agraphia — 
Amimia.J 

In  cases  of  this  kind  the  patient  is  unable  to  communicate 
his  thoughts  by  words  or  by  writing,  while  his  intellectual  pan- 
tomime is  impaired.  He  can  often  utter  words,  but  these  may  not 
possess  any  intellectual  value ;  in  the  words  of  Dr.  Hughlings- 
Jackson  the  patient  is  speechless  but  not  wordless.  The  words 
which  the  patient  can  utter,  as  a  rule,  continue  the  same  in  the 
same  patient — "  recurring  utterances."  Or  the  patient  may 
under  excitement  swear,  or  even  utter  a  phrase  appropriate  to 
the  surrounding  circumstance,  such  as  "  Good-bye,"  when  a 
friend  is  leaving.  It  will  be  readily  seen  that  the  "  recurring 
utterances"  such  as  "  Yes"  or  "  No,"  which  are  repeated  on  all 
occasions  whether  appropriate  or  not,  do  not  possess  any  intel- 
lectual value,  while  of  the  occasional  utterances  swearing  is  a 
purely  emotional  expression,  and  even  the  phrase  "  Good-bye" 
must  be  regarded  as  expressing  a  state  of  mental  regret  rather 
than  a  purely  intellectual  appreciation  of  the  surrounding  condi- 
tions. In  some  cases,  in  addition  to  the  usual  recurring  utter- 
ances of  "Yes"  and  "No,"  the  patient  repeats  such  phrases  as 
"Come  on  to  me" f  Jackson),  or  "I  want  protection"  (Paget).  The 
man  whose  recurring  utterance  was  "Come  on  to  me"  was  a  rail- 
way signalman,  and  had  been  taken  ill  on  the  rails  in  front  of  his 
box,  while  the  man  who  could  only  say  "  I  want  protection"  had 
his  left  cerebral  hemisphere  injured  in  a  brawl.  Dr.  Hughlings- 
Jackson  makes  the  very  probable  supposition  that  in  these 
cases  the  recurring  utterance  constituted  the  last  words  spoken 
or  which  were  in  a  state  of  mental  preparation  for  utterance 
when  the  damage  occurred  to  the  brain.  It  is  not  improbable 
that  words  uttered  or  about  to  be  uttered  during  a  period 
of  great  excitement  might  leave  permanent  traces  which 
would  render  them  liable  to  be  subsequently  uttered  as  inter- 
jectional  phrases  during  emotional  states.  That  all  these  words 
and  phrases  must  be  regarded  as  expressive  of  emotional  rather 
than  intellectual  states  is  shown  by  the  fact  that  the  patient  is 
frequently  unable  to  repeat  his  favourite  oath  or  his  formula 


THE   LOCALISATION   OF   THE  LESION.  617 

of  leave-taking,  or  perhaps  "  Yes  "  or  "  No"  when  asked  to  do 
so  (Broadbent). 

The  patient,  on  the  other  hand,  understands  all  that  is  said 
to  him,  and  remembers  what  is  read  to  him  or  what  he 
reads  himself.  His  articulatory  actions  are  well  performed,  and 
during  eating  and  swallowing  his  vocal  organs  act  normally, 
and  he  may  sing,  laugh,  smile,  and  frown  as  usual.  He  will 
point  to  objects  named  and  recognise  drawings  of  them,  pro- 
vided they  were  known  to  him  before  his  illness.  He  is  able 
to  play  at  cards  and  other  games,  and  recognises  handwriting. 
The  few  words  which  the  patient  can  use,  as  yes  or  no,  may  be 
uttered  with  such  variations  of  tone  and  gesture  as  to  indicate 
when  he  is  angry  or  joyful.  His  use  of  words  is,  in  accordance 
with  Mr.  Herbert  Spencer's  theory,  more  akin  to  song  than  to 
speech,  and  belongs  rather  to  emotional  than  to  intellectual 
language. 

So  far  we  have  considered  the  cases  of  those  patients  who  are 
completely  deprived  of  the  power  of  expressing  intellectual 
language  while  retaining  the  power  of  understanding  it,  but  we 
must  now  turn  our  attention  to  those  lesser  grades  of  ataxic 
aphasia  in  which  the  patient  still  retains  the  use  of  a  few  words 
or  phrases  of  real  speech  value.  We  have  seen  that  most 
aphasics  use  words  in  an  interjectional  sense,  and  when  excited 
oaths  or  phrases  as  "  God  bless  me "  may  be  uttered,  but 
these  also  must  be  regarded  as  compound  interjections  and  as 
purely  indicative  of  emotional  conditions.  Besides  the  interjec- 
tional use  of  words  and  phrases,  the  patient  may  occasionally 
utter  a  word  or  phrase  which  is  evidently  equivalent  to  a 
distinct  proposition.  He  may,  for  instance,  retain  the  full 
use  of  the  words  "yes"  and  "no,"  and  even  when  he  uses  "  no" 
to  express  assent  as  well  as  dissent,  he  may  be  able  by  the 
aid  of  pantomime  to  indicate  in  which  sense  he  intends  the 
word  to  be  understood.  Dr.  Hughlings-Jackson  mentions  the 
case  of  a  woman  who  could  only  utter  the  phrase  "  Yes,  but 
you  know,"  who  was  once  heard  to  say  "  Take  care  ! "  when  a 
child  was  in  danger  of  falling,  but  could  not  repeat  the  phrase 
when  asked  to  do.  It  cannot  be  denied  that  this  utterance 
possesses  an  intellectual  element,  inasmuch  as  it  is  an  appro- 
priate admonition  to  a  person  in  danger  of  falling.     It  must. 


618  FOCAL   DISEASES,   ACCORDING   TO 

however,  be  remembered  that  the  phrase,  although  appropriate 
to  the  occasion,  was  uttered  under  circumstances  calculated  to 
induce  alarm  and  excitement,  and  the  same  words  had  probably- 
been  frequently  repeated  under  similar  circumstances.  In  the 
slighter  defects  of  speech  the  patient  can  talk,  but  uses  a  word 
kindred  in  its  meaning  with  the  one  intended,  as  "  worm- 
powder"  for  "  cough-medicine,"  or  in  its  sound,  as  "  parasol"  for 
"  castor-oil"  (Jackson). 

(6)  Loss  or  iTnpairment  of  the  Regulative  department  of 
the  Impressive  faculty  of  Speech,  while  the  Expressive 
is  either  unaffected  or  only  secondarily  implicated. 
(Amnesic  Aphasia.) 

(1)  Loss  of  Memory  of  Names  or  Nouns. — In  many  cases 
of  loss  of  memory  for  words  the  names  of  things  are  forgotten, 
while  the  memory  for  dates,  events,  and  the  relations  between 
these  may  remain  good.  Dr.  Broadbent  mentions  the  following 
case  : — An  old  gentleman,  after  very  slight  right  hemiplegia, 
could  give  long  answers  fluently,  and  volunteer  statements,  so 
long  as  the  phrase  did  not  contain  a  noun. 

"  Oh,  yes  ;  I  am  much  better  than  when  you  last  saw  me."  "  I  shall 
be  73  on  the  three — four — • — ,"  when  he  confused  himself  in  trying  to  find 
the  word  December.  He  could  not  name  a  hand  when  told  to  do  so,  but 
in  his  effort  something  like  a  leg  was  once  heard.  This  gentleman's 
memory  of  facts,  events,  dates,  and  faces  is  very  good. 

The  patient  is  often  enabled  to  supply  the  want  of  a  noun 
by  a  paraphrase,  as  in  the  following  case,  quoted  by  Kussraaul 
from  Bergmann  : — 

"A  hind,  40  years  of  age,  was  unconscious  for  four  weeks  after  a 
severe  injury  of  the  head ;  he  regained  his  recollection  of  things  and 
places,  but  his  memory  for  names  was  lost.  The  nouns  had  disappeared 
from  his  vocabulary,  but  he  still  had  command  of  the  verbs.  A  pair  of 
scissors  he  called  that  with  which  one  cuts  ;  the  window,  that  through 
which  one  sees,  through  which  the  room  is  illuminated,  &c.  He  had 
forgotten  most  of  his  songs  and  prayers.     He  recovered  subsequently." 

Sometimes  the  initial  consonants  of  words  are  left  out  of 
words  in  speaking  and  writing  (Schlesinger),  while  in  a  case 
recorded  by  Graves  the  sight  of  persons  and  objects  merely 
suggested  the  initial  consonants  of  their  names,  the  rest  of  the 


THE   LOCALISATION    OF   THE   LESION.  619 

name  not  being  recalled  until  the  corresponding  written  word 
met  the  eye. 

"  A  man,  56  years  of  age,  after  an  apoplectic  attack,  lost  his  memory 
for  proper  names  and  substantives  in  general,  with  the  exception  of 
their  first  letters,  although  the  power  of  speech  was  not  impaired  in 
other  respects.  He  prepared  for  himself  an  alphabetically  arranged 
dictionary  of  the  substantives  required  in  his  home  intercourse,  and  when- 
ever it  became  necessary  for  him  to  use  a  noun  he  immediately  looked  it 
out  in  his  dictionary.  When  he  wished  to  say  '  Cow,'  he  looked  under  C. 
As  long  as  he  kept  his  eye  upon  the  written  name,  he  could  pronounce  it, 
but  a  moment  afterwards  he  was  unable  to  do  so." 

(2)  Inability  to  Express  the  Relations  between  Things. — Tu 
another  form  of  amnesic  aphasia  the  names  of  persons  and 
things  are  more  or  less  remembered,  but  the  memory  of  words 
indicative  of  relations  and  attributes  is  impaired. 

In  the  case  of  a  somewhat  complicated  disorder  of  speech  mentioned 
by  Dr.  Broadbent  the  patient  could  only  say  :  "  Brother,  brother — New 
York — America,  two  brothers  in  America — ^letter."  This  patient  was, 
therefore,  able  to  recall  the  names  of  the  persons  and  places  intended,  but 
could  not  express  the  relations  between  them  so  as  to  construct  a  sentence. 

(3)  In  another  disorder  of  the  receptive  faculty  of  speech  the 
patient  is  unable  to  name  any  object  which  he  sees,  or  to  read 
a  single  letter,  although  he  may  converse  fluently  and  write 
correctly  (word -blindness — word- deafness).  A  case  related  by 
Dr.  Broadbent  is  a  remarkable  example  of  this  affection. 

An  intelligent  man,  59  years  of  age,  after  an  acute  cerebral  attack, 
lost  completely  the  power  to  read  printed  or  written  words.  He  was 
also  unable  to  recall  the  name  of  the  most  famihar  object  presented 
to  him.  This  man  could,  however,  converse  fluently,  his  vocabulary  was 
large,  and  his  words  well  chosen  and  arranged,  although  he  occasionally 
forgot  the  names  of  streets,  persons,  and  things.  He  could  also  write 
easily  and  correctly  both  from  dictation  and  spontaneously.  He  died  from 
an  extensive  haemorrhage  into  the  left  temporal  lobe,  with  rupture  into 
the  lateral  ventricle.  Two  foci  of  softening  of  older  date  were  observed, 
one  being  situated  in  the  temporo-sphenoidal  lobe  beneath  the  posterior 
end  of  the  parallel  sulcus,  and  the  other  higher  up  underlying  the  angular 
gyrus,  and  between  it  and  the  point  where  the  descending  horn  of  the 
ventricle  is  given  off. 

(4)  In  a  fourth  form  of  amnesic  aphasia  the  patient  appa- 
rently fails  to  comprehend  written  or  spoken  language,  and  seems 
to  be  unconscious  that  his  speech,  which  consists  of  mere  jargon, 


620  FOCAL  DISEASES,   ACCORDING  TO 

is  uQintelligible  to  others.  The  following  brief  abstracts  of  two 
cases  described  by  Dr.  Broadbent  are  good  examples  of  this 
condition : — 

A  man,  aged  60  years,  who  had  previously  been  a  good  talker  and 
great  reader,  suflFered,  after  a  fit  of  some  kind,  from  a  peculiar  afiection  of 
speech,  paresis  of  the  right  side  of  the  face  but  no  hemiplegia.  His  speech 
was  a  mere  inarticulate  jargon.  When  asked  a  question  he  would  make  a 
brief  reply  as  if  he  understood  and  answered  ;  the  modulation  of  the 
voice  and  the  emphasis  were  perfectly  natural,  and  corresponded  with  the 
facial  expression  and  gestures,  but,  as  a  rale,  there  was  not  the  least  sem- 
blance to  words  in  what  he  said.  His  replies  were  often  so  suitable  in  length 
and  emphasis  that  it  might  have  been  supposed  that  he  had  comprehended 
the  question.  When,  however,  he  was  told  to  do  anything,  it  was  seen  that 
he  did  not  understand  the  simplest  phrase.  He  sat  up  in  bed  once  or  twice 
when  required  to  do  so,  but  as  this  was  not  made  a  test  question  there 
would  be  other  indications  of  what  was  wanted,  and  he  was  extremely  ready 
in  comprehending  signs.  When  told  to  give  his  hand  he  invariably  put  out 
the  tongue.  A  letter  addressed  to  him  at  the  hospital  being  handed  to  him, 
he  took  it,  appeared  to  read  the  name  and  address,  and  put  it  down  again. 
Not  attempting  to  open  it,  a  piece  of  paper  having  "  Give  me  your  hand  " 
written  upon  it  was  handed  to  him.  He  took  it,  held  it  so  as  to  get  a  good 
light  on  it,  and  then  having  apparently  read  it  laid  it  aside  without  giving 
his  hand,  though  asked  to  do  so  by  word  of  mouth  as  well  as  in  writing. 

The  patient  died  somewhat  suddenly,  and  at  the  autopsy  a  large  focus 
of  softening  was  found  in  the  left  hemisphere,  limited  to  its  posterior  half. 
Part  of  the  supra-marginal  lobule  was  yellow  in  colour,  shrunken  in 
volume,  and  soft.  This  condition  extended  upwards  and  backwards  to 
within  about  half  an  inch  of  the  longitudinal  fissure  just  in  front  of  the 
external  parieto-occipital  fissure,  involving,  therefore,  the  postero-parietal 
lobule.  The  morbid  change  implicated  the  angular  gyrus,  and  nearly 
reached  the  occipital  lobe  ;  the  adjacent  parts  of  the  temporo-sphenoidal 
lobe,  the  posterior  end  of  the  infra-marginal,  and  parallel  gyri  were  soft, 
but  not  wasted  or  discoloured  on  the  surface. 

The  affection  of  speech  in  the  following  case  reported  by 
Dr.  Broadbent  is  more  complicated  than  that  in  the  case  just 
described. 

The  patient  was  a  well-educated  and  intelligent  young  man,  who  had 
contracted  syphilis  eight  years  previous  to  the  date  of  the  report.  About 
a  fortnight  before  his  admission  into  St.  Mary's  Hospital  he  was  suddenly 
seized  with  hemiplegia  and  loss  of  speech.  He  appeared  to  understand 
all  that  was  said  to  him,  but  could  not  answer  questions  at  first,  although 
after  a  few  weeks  he  improved  so  much  as  to  be  able  to  reply  to  questions 
requiring  brief  and  simple  answers.    He  was,  however,  unable  to  give  a  con- 


THE   LOCALISATION   OF   THE  LESION.  621 

nected  account  of  anything  requiring  more  than  a  few  words.  His  method 
of  correcting  an  erroneous  statement  which  had  been  made  that  he  woke 
up  from  sleep  paralysed  and  speechless  was  as  follows :  "  No — evening, 
evening — put  down  my  cigar,  smoking,  smoking  not  a  quarter  of  an  hour — 
all  at  once  " — indicatin  g  by  gestures  the  loss  of  power  in  the  limbs  and 
adding — "  Couldn't  speak."  He  lost  at  first  all  knowledge  of  numbers,  and 
could  not  tell  how  many  2  and  2  made  ;  but  by  practice  he  could  in  a  few 
weeks  multiply  by  2  and  3  up  to  12. 

When  a  table,  glass,  inkstand,  and  violets  were  pointed  out  to  him,  he 
was  unable  to  name  them,  nor  could  he  name  his  gloves,  hat,  or  a  pen. 
He  named,  however,  some  objects,  such  as  his  hand  and  the  fire.  He  perused 
his  newspaper  regularly,  and  with  all  the  marks  of  intelligent  interest. 
He  understood  it  also,  for  he  went  to  the  sister  in  a  state  of  great  excite- 
ment to  tell  her  of  the  failure  of  a  firm  with  which  he  had  business  rela- 
tions, carrying  the  paper  in  his  hand,  and  pointing  out  the  announcement  ; 
and  he  could  always  find  a  given  paragraph,  when  asked  to  do  so  as  a  test. 
When,  however,  he  was  asked  to  read  aloud,  the  result  was  gibberish.  The 
following  passage  was  selected  : — "  You  may  receive  a  report  from  other 
sources  of  a  supposed  attack  on  a  British  Consul- General.  The  affair, 
however,  is  utterly  unworthy  of  consideration.  No  outrage  was  even 
intended,  and  the  report  was  due  to  misrepresentation  of  the  facts.  The 
Odessa  line  is  again  working  properly."  It  was  read  slowly,  and  in  a 
jerky  manner,  as  nearly  as  it  could  be  taken  down  thus  : — "  So  sur  wisjee 
coz  wenement  ap  ripsy  fro  fruz  fenement  wiz  a  seconce  coz  foz  no  Sophias  a 
thee  freckled  pothy  conollied.  This  affaise  eh  oh  cont  oh  curly  of  conse- 
quences. Uce  sudos  val  oh  es  es  entain  ah  thee  enepol  a  oh  dee  a  ah 
messequence  oh  coz  foz.  The  assoil  lens  a  puff  pifl  miss  corres  povety. " 
It  was  evidently  an  effort  to  read  aloud,  requiring  close  attention,  and  he 
read  seriously  and  steadily,  apparently  unconscious  of  the  absurdity  of  his 
utterances,  till  interrupted  by  laughter,  which  it  was  impossible  to  restrain, 
in  which  he  usually  joined.  He  was  never  able  to  give  the  simplest 
written  answer  to  a  question,  or  to  write  from  dictation,  but  he  signed  his 
name  quite  well,  and  wrote  down  the  names  of  his  brothers,  but  with  the 
initial  only  of  the  Christian  name,  the  surname  in  full. 

When  asked  to  copy  a  sentence,  he  wrote  the  short  words  quickly,  and 
in  a  good  hand  ;  but  a  long  word  he  took  down  slowly,  letter  by  letter, 
in  large  schoolboy  characters,  usually  accurately,  but,  as  he  wrote  each 
letter,  he  named  it  aloud,  and  always  wrongly. 

§  749.  Morbid  Anatomy. — So  far  as  is  known  of  the  morbid 
anatomy  of  cortical  disorders  of  speech  may  be  summed  up  in 
a  few  words.  A  comparison  of  a  large  number  of  observations 
shows  that  the  lesion  in  ataxic  aphasia  is  situated  in  the 
posterior  portion  of  the  third  frontal  convolution  and  the  ad- 
joining portion  of  the  Island  of  Reil  of  the  left  hemisphere.    In 


622 


FOCAL  DISEASES,  ACCORDING  TO 


exceptional  cases  the  disease  of  the  third  frontal  convolution 
has  been  found  in  the  right  instead  of  the  left  hemisphere,  and 
in  these  the  aphasia  was  associated  with  left  hemiplegia  during 
life  ;  the  patients  were  in  most  cases  known  to  be  left-handed. 
In  other  cases  of  right  hemiplegia,  but  without  aphasia,  the 
posterior  extremity  of  the  tliird  left  frontal  convolution  has 
been  found  disorganised  after  death,  and  in  such  cases  also  the 
patients  were  left-handed. 

The  portion  of  the  ascending  frontal  convolution  which 
adjoins  the  Island  of  Reil  is  often  involved  in  the  disease. 
The  lesion  generally  consists  of  occlusion — either  by  embolus 
or  syphilitic  thrombosis — of  the  left  middle  cerebral  artery,  or 
at  least  of  the  branch  which  supplies  Broca's  convolution. 

In  amnesic  aphasia,  on  the  other  hand,  the  lesion  is  in  the 
area  of  distribution  of  the  posterior  and  terminal  branches  of 
the  left  middle  cerebral  artery,  and  the  region  of  softening 
comprises  the  supra-marginal  and  postero- parietal  lobules,  the 
angular  gyrus  (visual  centre),  the  posterior  part  of  the  infra- 
marginal  convolution  (acoustic  centre)  and  the  convolutions 
bounding  the  parallel  and  collateral  fissures  (Broadbent). 

Lesions  that  damage  the  fibres  of  the  corpus  callosum 
which  connect  the  third  frontal  convolutions  of  the  two  sides, 
and  those  which  connect  the  third  left  frontal  convolutions  with 
the  internal  capsule,  produce,  as  has  been  pointed  out  by  Broad- 
bent,  as  permanent  an  affection  of  speech  as  destruction  of 
Broca's  convolution  itself. 

A  man,  aged  66  years,  whose  case  is 
reported  by  Pitres,  suffered  from  rigtit  hemi- 
plegia, with  embarrassment,  and  finally 
complete  loss  of  speech.  At  the  autopsy,  two 
small  patches  of  yellow  softening  were  found 
in  the  cortex  of  the  left  hemisphere,  one  being 
situated  upon  the  superior  parietal  lobule,  and 
the  other  upon  the  lobule  of  the  pli  courhe. 
No  changes  were  observed  in  the  third  frontal 
convolution,  but  a  large  focus  of  softening 
was  observed  in  the  centrum  ovale,  which 
extended  anteriorly  to  the  part  underlying 
the  posterior  extremity  of  the  third  frontal 
convolution,  and  posteriorly  beyond  the  pos- 
terior extremity  of  the  optic  thalamus  {Fig. 
264,  L). 


Fig.  264. 


THE   LOCALISATION   OF  THE   LESION.  623 

§  750.  Morbid  Physiology. — When  the  structure  of  the  cor- 
tex at  the  posterior  extremity  of  the  third  left  frontal  convolu- 
tion is  thoroughly  disorganised,  the  expressive  faculty  of  speech 
is  arrested  at  its  origin.  The  patient  can  understand  everything 
that  is  said  to  him,  he  can  think  and  probably  clothe  his  ideas 
in  suitable  subjective  language,  but  the  objective  or  expressive 
part  of  speech  is  entirely  lost.  He  can  understand  the  thoughts 
of  others,  but  cannot  communicate  his  thoughts  to  others  either 
by  spoken  or  written  language  or  by  gesture.  Most  aphasics 
present  apparent  exceptions  to  this  rule,  inasmuch  as  the 
majority  of  them  are  not  quite  destitute  of  the  power  of  uttering 
words.  But,  as  pointed  out  by  Dr.  Hughlings-Jackson,  a  patient 
may  be  completely  speechless  though  not  entirely  wordless. 
The  words  that  aphasic  patients  use  are  recurring  utterances 
like  "  Yes "  and  "  No,"  which  are  repeated  on  all  occasions, 
whether  appropriate  or  not.  The  patients  have  only  an  inter- 
jectional  and  not  a  cognitional  use  of  these  words,  and  they 
must  be  regarded  as  part,  not  of  intellectual,  but  of  emotional 
language.  The  patient  may  be  able  to  swear,  oaths  being  part 
of  emotional  language.  Dr.  Hughlings-Jackson  thinks  that 
as  actions  become  more  and  more  automatic  they  tend  to 
become  organised  in  the  right  as  well  as  in  the  left  hemisphere, 
and  he  believes  that  the  recurring  utterances  and  phrases  used 
by  aphasics  are  those  which  had  become  automatic  either 
previous  to  or  during  the  attack,  and  consequently  organised  in 
the  right  hemisphere.  The  words  which  become  automatic 
are  those  like  "Yes"  and  "No,'"  which  have  been  frequently 
repeated  in  the  experience  of  the  individual,  and  words  of 
the  character  of  oaths,  which,  although  they  may  not  neces- 
sarily have  been  frequently  used  by  the  patient,  have  been 
used  under  circumstances  of  excitement  and  are  expressive  of 
emotional  states.  In  those  cases  in  which  the  patient  can 
repeat  words  in  the  form  of  a  propositiou,  such  as  the  man 
mentioned  by  Paget,  who  was  injured  in  a  brawl,  and  who 
could  only  say  "  I  want  protection,"  it  is  thought  probable  by 
Dr.  Hughlings-Jackson  that  the  patient  was  about  to  repeat 
the  words  at  the  moment  of  injury.  He  thinks,  therefore,  that 
these  words  had  become  automatic  in  him  by  being  repeated 
under  circumstances  of  great  excitement.   But  whatever  may  be 


624  FOCAL   DISEASES,    ACCORDING  TO 

the  explanation  of  the  recurrence  of  such  phrases,  it  is  obvious 
that  they  possess  no  value  as  a  form  of  intellectual  expression, 
inasmuch  as  they  are  repeated  without  any  reference  to  their 
appropriateness  to  surrounding  circumstances. 

But  what  explanation  can  be  given  of  the  fact  that  the  com- 
plex muscular  movements  which  serve  for  intellectual  expression 
are  organised  in  one  hemisphere  only  ?  Accepting  the  crossed 
connection  of  the  hemispheres  of  the  brain  with  the  muscles 
of  the  trunk  and  limbs  as  a  fact,  there  can  be  no  difficulty 
in  understanding  why  in  right -handed  people  the  more  special 
muscular  adjustments  of  the  hand  should  be  organised  in  the 
left  hemisphere.  It  seems  strange,  however,  that  the  muscular 
movements  concerned  in  articulation  should  follow  the  same 
rule.  It  must  at  least  be  admitted  that  it  would  be  an  economy 
of  force  if  the  muscles  of  the  two  sides  concerned  in 
articulation  were  regulated  from  one  hemisphere,  and  it  is 
also  probable  that  a  greater  precision  in  the  execution  of 
these  movements  is  obtained  by  a  unilateral  organisation.  It 
is  likewise  somewhat  difficult  to  understand  why  in  left-handed 
people  both  the  structural  correlatives  of  the  more  special  move- 
ments of  the  hand  and  of  the  articulatory  movements  of  spoken 
language  are  found  together  in  the  right  hemisphere.  But 
whatever  may  be  the  explanation,  there  is  abundant  clinical 
evidence  that  such  is  the  case. 

If  then  ataxic  aphasia  be  caused  by  a  destroying  lesion  of 
the  emissive  organisation  of  speech,  it  might  be  supposed  that 
simple  severance  of  the  cortical  organisation  from  the  executive 
organisation  would  produce  the  same  effect.  In  other  words, 
it  may  be  supposed  that  disease  of  the  fibres  of  the  pyramidal 
tract,  which  connect  the  posterior  extremity  of  the  third  frontal 
convolution  and  the  nerve  nuclei  in  the  medulla,  would  produce 
the  same  effect  as  disease  of  the  cortex  itself.  When  a  com- 
mander-in-chief, for  instance,  sends  orders  to  a  general  of 
division  to  execute  a  particular  movement,  the  latter  cannot 
obey  the  order  unless  the  line  of  communication  between 
the  two  be  kept  open,  no  matter  how  effective  may  be  the 
organisation  of  the  emissive  department  of  intelligence  at  its 
central  end.  But  it  so  happens  in  war  that  when  the  direct 
line  of  communication  is  cut  off,  an  indirect  one  may  be  dis- 


THE   LOCALISATION   OF   THE   LESION.  625 

covered.  And  something  of  this  nature  occurs  in  aphasia 
caused  by  disease  of  the  pyramidal  tract.  We  have  already 
seen  that  the  fibres  of  the  knee  of  the  internal  capsule  connect 
the  third  frontal  convolution  and  the  nuclei  of  articulation  in 
the  medulla,  and  when  these  are  interrupted  on  the  left  side, 
the  patient  suffers  from  temporary  loss  of  speech.  But,  as  has 
been  pointed  out  by  Dr.  Broadbent,  the  patient  under  these 
circumstances  makes  a  good  and  moderately  rapid  recovery. 
The  explanation  given  by  Dr.  Broadbent  of  this  rapid  recovery 
is  that,  although  the  direct  line  of  communication  between  the 
emissive  organisation  and  the  executive  is  cut  off,  an  indirect 
line  is  readily  established. 

The  usual  course  is  for  the  message  to  be  conducted 
downwards  by  the  fibres  of  the  left  pyramidal  tract  and  to 
cross  over  in  the  medulla  to  the  nuclei  of  articulation  of  the 
opposite  side,  and  then  through  commissural  fibres  to  the  nuclei 
of  the  same  side.  But  when  this  channel  is  interrupted  the 
message  is  sent  from  the  left  third  frontal  convolution  through 
the  fibres  of  the  corpus  callosum  to  the  corresponding  convolu- 
tion of  the  right  side,  and  from  the  latter  through  the  right 
pyramidal  tract  to  the  nuclei  of  articulation  of  the  opposite  side, 
and  through  commissural  fibres  to  the  nuclei  of  the  same  side 
(§89).  In  this  way  the  organisation  in  the  third  left  frontal 
convolution  can,  after  a  time,  be  utilised,  but  during  the  time 
occupied  in  opening  the  new  channels  of  communication  the 
patient  suffers  from  greater  or  lesser  degrees  of  disturbances  of 
speech.  But,  as  has  been  pointed  out  by  Broadbent,  when  the 
fibres  of  the  pyramidal  tract  in  connection  with  the  hemisphere 
and  the  fibres  of  the  corpus  callosum  which  connect  the  third 
frontal  convolutions  of  the  two  sides  are  both  interrupted  by  a 
lesion  in  the  centrum  ovale,  the  affection  of  speech  is  as  perma- 
nent as  if  the  third  frontal  convolution  itself  were  completely 
disorganised. 

Speech,  in  its  objective  or  expressive  aspect,  consists  of 
highly  special  and  complex  movements,  and  the  question  arises, 
why  are  cases  of  aphasia  not  associated  with  paralysis  of  the 
muscles  of  articulation  ?  The  reply  is  that  although  there  is 
not  a  paralysis  of  the  separate  actions  of  the  muscles  of  arti- 
culation, yet  there  is  a  paralysis  of  the  combinations  of  action 
00 


626  FOCAL   DISEASES,   ACCOKDING  TO 

which  are  necessary  for  the  production  of  speech.  That  ataxic 
aphasia  is  of  a  paralytic  nature  may  be  shown  in  several  ways. 
The  third  left  frontal  convolution,  for  instance,  is  situated  near 
the  centres  for  the  regulation  of  the  movements  of  the  inferior 
facial  muscles  and  of  the  muscles  of  one-half  of  the  tongue,  so 
that  the  aphasia  caused  by  disease  of  Broca's  convolutions  is 
associated  with  unilateral  facial  and  lingual  paralysis  even  in  the 
slighter  cases  in  which  complete  hemiplegia  is  not  produced. 
But  still  more  cogent  evidence  in  favour  of  this  view  may  be 
derived  from  cases  of  bilateral  diseases  of  the  hemispheres,  affect- 
ing either  the  third  frontal  convolutions  or  the  tracts  of  fibres 
which  connect  these  with  the  nuclei  in  the  medulla,  and  in 
which  there  is  not  only  paralysis  of  the  special  but  also  of  the 
general  movements  of  articulation  (anarthria).  For  the  follow- 
ing example  of  this  affection  I  am  indebted  to  Dr.  Leech,  who 
kindly  transferred  the  case  to  me  ten  days  before  the  patient 
died.  The  notes  of  the  case  were  taken  by  Mr.  Gordon,  when 
the  patient  was  under  the  care  of  Dr.  Leech,  and  by  Mr. 
Luckman  after  he  came  under  my  care. 

Joseph  C ,  aged  49  years,  was  admitted  iinder  the  care  of  Dr. 

Leech,  November  15th,  1880.  The  patient  was  healthy  until  about  eleven 
months  ago,  when  he  began  to  complain  of  headache,  usually  situated  in 
the  temples  and  occasionally  in  the  back  of  the  head.  It  was  also  observed 
about  this  time  that  his  speech  was  "  thick,"  but  no  other  notable  symp- 
toms were  observed.  Four  and  a  half  months  ago  he  fell  out  of  bed  three 
or  four  times  the  same  night,  and  was  unable  to  get  in  again  until  assisted 
by  his  wife  and  son.  From  that  time  up  to  the  present  his  speech 
appeared  to  have  become  more  and  more  unintelHgible,  while  he  com- 
plained of  general  weakness,  but  there  was  no  distinct  i^aralysis  of  any  of 
the  extremities. 

Present  Condition. — The  patient  is  emaciated  and  feeble,  so  that  he 
soon  tires  on  attempting  to  walk,  but  there  is  no  paralysis  of  the  extremi- 
ties. There  is  considerable  loss  of  facial  expression,  and  the  patient 
cannot  compress  his  hps  or  whistle,  but  can  blow  out  a  candle  with 
tolerable  facihty.  He  can  protrude  his  tongue,  but  cannnot  curl  the 
tip  up  towards  his  nose,  or  roll  it  up  laterally  so  as  to  render  it  tubular. 
His  speech  is  almost  iminteUigible,  and  great  attention  is  necessary  in 
order  to  imderstand  the  few  words  he  is  able  to  utter.  He  can  pronounce 
the  separate  consonants  with  tolerable  distinctness,  but  finds  difiiculty 
with  the  labials  and  dentals,  the  letters  c,  d,  f,  I,  m,  n,  s,  t,  x,  h,  and  w 
giving  him  the  greatest  difficulty.  Food  collects  between  his  teeth,  viscid 
saliva  collects  in  his  mouth,  which  has  to  be  constantly  wiped  away,  and 


THE   LOCALISATION   OF  THE  LESION.  627 

the  power  of  deglutition  is  impaired.  His  arteries  are  atheromatous, 
but  no  other  important  general  symptoms  are  present. 

Nov.  26.  He  has  complained  of  pain  for  the  last  few  days  over  the 
temporal  region.  The  nurse  reports  that  he  has  been  shghtly  delirious  at 
times  for  the  last  few  days,  that  he  got  out  of  bed  several  times  yesterday, 
and  that  on  one  occasion  he  fell  down  and  had  to  be  assisted  into  bed. 
Dm-ing  this  attack  he  is  reported  to  have  been  conscious,  but  his  speech 
was  greatly  affected,  and  there  was  some  degree  of  paralysis  of  both  the 
lower  extremities.  There  is  at  present  no  distinct  loss  of  power  in  either 
the  legs  or  the  arms,  but  his  speech  is  more  unintelligible  than  at  any 
time  since  his  admission. 

Dec.  1.  The  patient  is  now  suffering  from  diarrhoea,  and  there  are 
marked  fluctuations  of  the  temperature  curve.  The  u\'ula  is  somewhat 
pendulous,  although  not  distorted,  and  its  reflex  excitabihty  is  dimyiished. 
The  fauces  and  epiglottis  can  be  examined  with  the  point  of  the  finger 
without  provoking  a  cough,  while  the  patient  exhibits  a  remarkable  toler- 
ance to  laryngoscopic  examination.  The  vocal  cords  move  normally  during 
respiration  and  phonation. 

Dec.  10.  Since  last  report  the  diarrhoea  has  proved  intractable  to  treat- 
ment, and  the  patient  is  much  feebler,  the  temperature  curve  presents 
marked  variations  in  the  course  of  twenty-fom-  hours,  being  at  noon  yester- 
day below  97°  F.,  and  at  midnight  105°  F.  Duriag  the  previous  thirteen 
days  the  temperature  varied  from  between  96-5°  F.  and  97*5°  F.  in  the 
morning  to  between  101-5°  F.  and  103-5'' F.  in  the  evening.  The  speech 
has  been  for  some  days  quite  unintelligible.  The  patient  now  became 
gradually  comatose,  and  died  in  the  evening. 

The  post-mortem  examination  was  conducted  by  Dr.  A.  H.  Young 
twenty-four  hours  after  death.  The  arachnoid  over  the  anterior  part  of 
the  convexity  of  the  brain  was  opaque,  and  the  subarachnoid  tissue 
oedematous,  but  the  membranes  were  healthy  posteriorly  and  over  the 
base.  Each  cerebral  hemisphere  presented  a  single  weU-defined  cystic 
cavity,  containing  clear  straw-coloured  flmd,  and  occupying  the  positions 
of  the  lenticular  nuclei.  In  the  left  hemisphere  the  lenticular  nucleus  was 
simply  replaced  by  the  cyst,  but  in  the  right  the  cavity  was  considerably 
larger  than  the  area  of  the  nucleus,  extending  anteriorly  slightly  beyond 
the  anterior  extremity  of  the  caudate  nucleus,  and  posteriorly  to  the  wall  of 
the  descending  horn  of  the  lateral  ventricle,  although  it  did  not  commu- 
nicate with  the  latter.  The  claustrmn  and  internal  capsiile  on  each  side 
were  unafiected.  The  ventricles  contained  a  shght  excess  of  fluid.  The 
arteries  at  the  base  of  the  brain  were  atheromatous.  The  mucous  mem- 
brane of  the  rectmn  and  descending  colon  was  covered  by  deep  ulcei^s,  with 
thickened  margins. 

^Microscopic  examination  showed  that  the  nerve  nuclei  in  the  medulla 
were  healthy,  and  no  descending  changes  could  be  detected  in  the  pyra- 
midal tracts  in  any  part  of  their  course. 


628  FOCAL  DISEASES,  ACCORDING  TO 

Dr.  Barlow  was  probably  the  first  to  draw  attention  to  the 
fact  that  lesions,  symmetrically  situated  in  the  hemispheres, 
may  produce  symptoms  closely  simulating  those  of  bulbar 
paralysis.  A  boy,  aged  10  years,  suffering  from  aortic  disease, 
had  an  attack  of  right  hemiplegia  with  aphasia,  from  which  he 
made  a  good  recovery.  Four  months  subsequently  he  had  an 
attack  of  left  hemiplegia  with  aphasia,  as  well  as  paralysis  of 
the  muscles  of  articulation,  those  concerned  in  the  first  act  of 
deglutition,  and  of  the  muscles  of  mastication.  At  the  autopsy 
evidence  of  an  embolus  was  found  in  both  Sylvian  arteries, 
l^he  obliteration  of  the  vessel  on  each  side  was  associated  with 
a  focus  of  softening,  about  the  size  of  a  shilling,  and  situated 
in  the  inferior  part  of  the  ascending  frontal  convolution,  and 
the  posterior  extremities  of  the  second  and  third  frontal  con- 
volutions. Soon  afterwards  an  important  paper  was  contri- 
buted by  Ldpine  on  this  subject.  In  the  case  observed  by 
this  author  the  symptoms  were  more  or  less  similar  to  those 

just  described  in  the  case  of  Joseph  C ,  but  in  the  former 

the  difi&culty  of  deglutition  was  more  marked  than  in  the 
latter.  At  the  autopsy  a  diseased  focus  was  found  in  each 
hemisphere,  involving  the  external  capsule  and  the  second 
and  third  divisions  of  the  lenticular  nucleus,  while  that 
in  the  right  hemisphere  extended  to  the  convolutions  of  the 
Island  of  Reil  and  the  posterior  extremity  of  the  third  frontal 
convolution.  Another  case  of  the  same  kind  is  quoted  by 
Ldpine  from  Oulmont. 

Lupine  also  refers  to  a  case  reported  many  years  ago  by 
Magnus,  in  which  anarthria  was  caused  by  a  unilateral  lesion 
of  the  brain,  the  disease  being  situated  in  the  corpus  striatum 
of  the  right  hemisphere.  Another  case  is  reported  by  Kirchoff  in 
which  bulbar  symptoms  were  caused  by  a  diseased  focus  situated 
in  the  right  hemisphere,  the  left  being  healthy.  The  cases  in 
which  the  lesion  was  unilateral  appear  to  show  that  the  general 
or  more  automatic  movements  of  bilaterally  associated  muscles 
are  often  regulated  almost  entirely  from  the  right  hemisphere  of 
the  brain.  Cases  of  this  kind  suggest  the  question  as  to  whether 
the  bulbar  symptoms  were  caused  directly  by  the  lesion  of  the 
lenticular  nucleus  or  indirectly  by  implication  of  the  fibres  of 
the  knee  of  the  internal  capsule.     In  the  case  observed  by  me 


THE   LOCALISATION   OF   THE   LESION.  629 

the  most  careful  microscopical  examination  of  the  crusta,  pons, 
anterior  pyramids  of  the  medulla,  and  spinal  cord  failed  to 
detect  any  descending  changes  in  the  pyramidal  tracts.  The 
cysts  in  the  hemispheres  were,  however,  very  much  distended 
with  fluid,  and  it  is  quite  probable  that  a  certain  amount  of 
pressui'e  was  thus  exercised  upon  the  fibres  of  the  internal 
capsule,  sufficient  to  partially  interrupt  conduction  through 
them,  without  being  sufficient  to  cause  secondary  degeneration. 
This  question  must,  therefore,  be  left  for  future  observations  to 
determine. 

The  mechanism  by  which  the  different  forms  of  amnesic 
aphasia  is  produced  is  much  more  difficult  to  comprehend  than 
that  of  the  ataxic  variety.  In  order  to  facilitate  the  compre- 
hension of  the  various  forms  of  aphasia,  several  authors  have 
constructed  diagrams  to  represent  hypothetically  the  nervous 
mechanism  concerned  in  speech.  The  best  of  these  are  the 
diagrams  of  Kussmaul  and  of  Broadbent,  and  although  not 
entirely  agreeing  with  either  of  them,  we  shall  avail  ourselves 
of  the  diagrams  of  the  latter.  Dr.  Broadbent  sets  out  in  his 
explanation  with  the  proposition  "  that  all  muscular  movements 
are  performed  under  the  direction  of  a  'guiding  sensation.'"  It 
would  have  been  better  if  he  had  said  under  the  guidance  of 
"centripetal  impulses"  instead  of  "sensation,"  inasmuch  as 
muscular  movements  take  place  in  the  entire  absence  of  sensa- 
tion. If,  for  example,  the  palm  of  the  hand  of  a  person  asleep 
be  tickled,  the  hand  closes  under  the  guidance  of  centripetal 
impulses,  but  independently  of  sensation,  the  action  in  this 
case  being  reflex.  But  when  the  individual  is  awake  the  out- 
going portion  of  the  reflex  arc  can  be  utilised  by  the  cortex  of 
the  brain,  and  then  voluntary  closure  of  the  hand  takes  place. 
The  nuclei  of  the  motor  fibres  of  the  peripheral  nerves  in  the 
spinal  cord  are,  therefore,  subservient  both  to  centripetal  im- 
pulses coming  from  the  periphery,  and  to  centrifugal  impulses 
coming  from  the  cortex  of  the  brain.  But  the  centrifugal  im- 
pulses from  the  cortex  are  initiated  and  controlled  by  centripetal 
impulses  coming  towards  the  cortex  from  the  periphery.  It 
thus  appears  that  each  movement  is  represented  in  the  anterior 
grey  horns  of  the  cord  by  a  group  of  connected  cells,  and  that 
this  group  may  be  called  into  activity  by  centripetal  impulses 


630 


FOCAL   DISEASES,  ACCORDING  TO 


coming  from  the  periphery  to  the  same  level  of  the  cord,  or  by 
centrifugal  impulses  from  a  higher  nerve  centre,  or,  in  Dr. 
Broadbent's  words,  "  a  motor  cell-group  is  formed  under  the 
guidance  of  a  sensory  cell-group  on  the  same  level,  and,  when 
formed,  is  made  use  of  by  a  higher  centre." 

The  "motor  cell-group"  in  the  case  of  speech,  which  for  the 
sake  of  convenience  Dr.  Broadbent  calls  a  word-group,  must 
combine  into  orderly  action  the  thoracic  muscles  in  order  to 
obtain  an  expiratory  current  of  air,  the  laryngeal  muscles  for 
phonation,  and  the  muscles  of  the  lips  and  tongue  for  articula- 
tion. I  shall  follow  Dr.  Broadbent  in  placing  the  word-groups 
in  the  corpus  striatum,  although  in  my  opinion  it  would  have 
been  better  had  he  discarded  this  ganglion  from  the  explana- 
tion and  merely  spoken  of  the  cortex  and  medulla  oblongata, 
which  are  connected  with  one  another  by  straight  fibres. 

When  the  cells  of  the  word-group  are  called  into  action  by 
centripetal  impulses  on  the  same  level,  the  action  is  reflex,  and 
the  resulting  contraction  would  simply  represent  a  complicated 
muscular  adjustment  without  any  reference  to  intellectual  ex- 
pression, and  it  is  only  when  its  activity  is  evoked  from  the  cortex 
that  the  movement  becomes  subservient  to  speech.  The  cortical 
outlet  for  speech  is  situated  in  the  third  left  fronta]  convolution, 
while  the  cortical  guiding  sensory  centre  for  spoken  language  is 
situated  in  the  superior  temporo-sphenodial  convolution  (auditory 
centre).  In  accordance  with  the  annexed  diagram,  lesion  of  S, 
the  speech  centre,  will  cause  ataxic  aphasia,  and  lesion  of  A,  the 

auditory  perceptive  centre,  or  of 
as,  the  fibres  which  connect  the 
inlets  and  outlets,  will  cause  dif- 
ferent forms  of  "  mistakes  in 
words."  A  hypothetical  explana- 
tion is  thus  afforded  for  three 
disorders  of  speech.  In  lesion  of 
S  the  "way  out"  for  all  the  mus- 
cular adjustments  concerned  in 
intellectual  expression  is  de- 
stroyed ;  in  lesion  of  a  s,  the 
line  of  communication  between 
the  guiding  sensory   centre  and 


Fig.  265. 


THE  LOCALISATION   OF  THE   LESION. 


631 


the  motor  outlet  is  damaged,  and  mistakes  in  words  recognisable 
by  the  patient  occur ;  while  in  lesion  of  the  sensory  centre  A, 
mistakes  in  words  occur,  of  which  the  speaker  remains  un- 
conscious. 

But  in  intellectual  expression  still  higher  centres  are  en- 
gaged, and  diseases  of  these  produce  various  complicated 
disorders  of  speech.  "  The  formation  of  an  idea  of  any  ex- 
ternal object,"  says  Dr.  Broadbent,  "  is  the  combination  of  the 
evidence  respecting  it  received  through  all  the  senses ;  for  the 
employment  of  this  idea  in  intellectual  operations  it  must  be 
associated  with  and  symbolised  by  a  name.  The  structural 
arrangement  corresponding  to  this  process  I  have  supposed  to 
consist  in  the  convergence  from  all  the  '  perceptive  centres'  of 
tracts  of  fibres  to  a  convolutional  area  (not  identified),  which 
may  be  called  the  '  idea  centre'  or  '  naming  centre.'  This  will 
be  ou  the  sensory,  afferent,  or  upward  side  of  the  nervous 
system ;  its  correlative  motor  centre  will  be  the  propositionising 
centre,  in  which  names  or  nouns  are  set  in  a  framework  of  other 
words  for  outward  expression,  and  in  which  a  proposition  is 
realised  in  consciousness  or  mentally  rehearsed.  If  we  are  to 
have  a  seat  of  the  faculty  of  language,  it  would  be  here  rather 
than  in  the  third  left  frontal  convolution,  with  which,  however, 
it  may  possibly  be  in  close  proximity.  Expressing  this  by  a 
diagram,  we  have  V,  A,  and  T,  the  visual  (angular  gyrus,  Ferrier), 
auditory  (infra-marginal  Sylvian 
g}Tus),  and  tactual  (uncinate 
gyrus),  perceptive  centres  send- 
ing converging  tracts  of  fibres, 
vn,  an,  tn,  to  N,  the  '  naming 
centre.'  Here  the  perceptions 
from  V  and  T  (smell  and  taste 
are  omitted  for  the  sake  of  sim- 
plicity) are  combined  into  an 
idea,  which  idea  is  symbolised  by 
the  name  reaching  N  through  A- 
which  has  always,  in  the  expe- 
rience of  the  individual,  been 
associated  with  the  object.  P  is 
the    propositionising    centre     in 


Fig.  266. 


632  FOCAL   DISEASES,   ACCOEDING  TO 

which  the  phrase  is  formed,  its  relations  with  N  and  S  being 
sufficiently  clear." 

According  to  this  scheme  lesion  of  the  naming  centre  N 
would  cause  loss  of  the  memory  of  names  or  nouns,  leaving 
the  patient  able  to  express  himself  imperfectly  in  words  indi- 
cative of  relations  and  attributes. 

Lesion  of  P,  the  propositionising  centre,  would  render  the 
patient  unable  to  construct  a  sentence  although  retaining  the 
use  of  names.  This  condition  is  illustrated  by  the  patient  who 
could  say  "brother,  brother — New  York — America — two  bro- 
thers— Am  erica — brother." 

Lesion  of  vn,  the  channel  of  communication  between  the 
visual  perceptive  centre  V  and  the  naming  centre  N,  would 
explain  cases  of  word-blindness ;  while  cases  in  which  the  lesion 
is  situated  in  the  auditory  perceptive  centre  A,  or  its  line  of 
communication  (a  n)  with  the  naming  centre,  would  explain 
cases  of  word-deafness. 

When  the  lesion  involves  more  than  one  of  the  sensory 
centres  or  their  lines  of  communication  with  the  naming  centre, 
it  is  manifest  that  complicated  disorders  of  speech  will  arise, 
difficult  to  analyse  into  their  separate  factors.  What  has  here 
been  said  with  regard  to  spoken  speech  may  bo  extended  to 
written  speech  and  intellectual  pantomime,  inasmuch  as  all 
forms  of  intellectual  expression  are  usually  involved  in  the 
disorder, 

I  have  so  far  endeavoured  to  give  a  succinct  account  of 
Dr.  Broadbent's  theory  of  aphasia,  while  making  use  as  much 
as  possible  of  his  own  words.  It  would  be  comparatively  easy 
to  criticise  this  scheme,  but  not  so  easy  to  construct  a  better.  I 
do  not,  for  instance,  like  Dr.  Broadbent's  use  of  the  phrase, 
"  perceptive  centre."  If  I  look  at  a  patch  of  yellow  colour 
before  me  and  perceive  that  it  is  caused  by  what  I  know  as  an 
"  orange,"  it  is  because  along  with  a  vivid  sensation  of  colour  I 
feel  a  faint  revival  of  tactual,  gustatory,  and  other  sensations 
previously  experienced  in  conjunction  with  a  similar  sensation 
of  colour.  If  I  stretch  out  my  hand  and  find  that  the  faint 
tactual  sensation  I  feel  along  with  the  visual  sensation  cannot 
be  converted  into  a  vivid  sensation,  I  call  the  patch  of 
colour,  not  an  orange,  but  an  illusion,  and  I  begin  to  think 


THE   LOCALISATION    OF   THE   LESION.  633 

that  my  senses  have  played  me  false.  The  physical  corre- 
lative of  a  perception  must,  therefore,  be  excitation  of  a 
portion  of  the  cortex  of  the  brain  in  which  all  the  sensory 
inlets  are  variously  combined,  and  would,  therefore,  correspond 
in  the  diagram  to  Dr.  Broadbent's  naming  centre,  while  his 
perceptive  should  be  described  as  sensory  centres.  On  the 
other  hand,  I  see  no  good  grounds  for  postulating  the  existence 
of  a  naming  as  distinct  from  a  perceptive  centre. 

The  process  of  naming  demands  a  large  increase  in  the  size 
of  the  perceptive  centre,  but  not  the  existence  of  a  separate 
centre.  Suppose,  for  instance,  again,  that  I  have  an  ocular 
perception  of  an  orange,  the  presentative  element  in  the  cog- 
nition is  a  vivid  feeling  of  a  yellow  colour,  and  the  repre- 
sentative elements  faint  revivals  of  previously  experienced 
feelings  of  touch  and  taste.  I  now  close  my  eye  and  hear  the 
word  "  orange"  spoken,  the  sound  of  the  word  forms  the  presen- 
tative element  of  the  cognition  aroused,  while  the  representative 
element  as  before  consists  of  faint  revivals  of  touch  and  taste, 
and  of  sight  also  now.  The  process  of  naming  is,  therefore,  a 
method  by  means  of  which  artificial  symbols  are  linked  on  to 
groups  of  previously  experienced  feelings,  and  although  the 
exercise  of  this  function  demands  a  great  extension  and  com- 
plication on  the  perceptive  centre  of  animals,  yet  it  does  not 
demand  the  formation  of  a  separate  centre  for  its  exercise. 
Again,  I  hardly  think  that  Dr.  Broadbent  has  shown  sufficient 
grounds  for  assuming  the  existence  of  a  distinct  propositionising 
centre,  but  I  prefer  not  to  enter  upon  a  criticism  of  this  portion 
of  his  scheme. 

6.  Lesions  in  the  Area  of  Distribution  of  the  Posterior 
Cerebral  Artery. 
The  posterior  cerebral  artery  supplies,  as  we  have  already 
seen,  the  temporo-sphenoidal  and  occipital  lobes,  with  the  ex- 
ception of  the  superior  temporo-sphenoidal  convolution,  which 
receives  branches  from  the  Sylvian  artery.  The  experiments 
of  Ferrier  and  others  appear  to  show  that  the  functions  of 
the  cortex  of  these  lobes  are  purely  sensory,  and  tUat  it  is 
directly  connected  with  centripetal  fibres,  and  only  indirectly 
with  centrifugal  fibres  through  the  cortex  of  the  parietal  lobes. 


634  FOCAL  DISEASES,  ACCORDING  TO 

Disease  of  the  cortex  of  the  temporo-sphenoidal  and  occipital 
lobes,  however,  does  not  give  rise  to  localised  motor  disturbance, 
and,  contrary  to  what  the  results  of  experiments  on  animals 
would  lead  us  to  expect,  distinct  sensory  disorders  are  also 
wanting.    Lesions  of  these  lobes  are,  as  a  rule,  latent 

Lesions  of  the  Occipital  Lobes. — Ferrier  quotes  a  case  reported  by 
Vauttier  of  yellow  softening  of  the  right  occipital  lobe  and  of  the  internal 
aspect  of  the  left  lobe  (quadrilateral  lobule).  There  was  neither  disorder  of 
motion  nor  sensation,  and,  with  the  exception  of  considerable  hebetude, 
there  were  no  symptoms  of  a  cerebral  affection.  Pitres  reports  a  Case 
in  which  an  abscess,  the  size  of  a  billiard-ball,  formed  in  the  posterior- 
inferior  aspect  of  the  brain.  There  were  no  sensory  or  motor  disorders, 
■  mental  obtuseness  being  the  only  indication  of  a  cerebral  lesion.  In  a 
case  which  came  to  the  post-mortem  table,  when  I  was  pathologist  to  the 
Manchester  Royal  Infirmary,  a  traumatic  abscess,  about  the  size  of  a 
hen's  egg,  occupied  the  right  occipital  lobe,  destroying  nearly  the  whole 
of  its  white  substance.  Dr.  Dreschfeld,  who  saw  the  patient  during  life, 
assured  me  that,  with  the  exception  of  temporary  hyperaesthesia  of  the 
left  side  of  the  body,  there  was  no  disorder  of  the  general  or  special 
senses.  The  patient  suffered  from  delirium  and  general  convulsions,  but 
these  symptoms  were  probably  due  to  the  presence  of  meningitis,  which 
had  spread  over  the  occipital  and  parietal  lobes  of  both  hemispheres. 
Many  similar  cases  are  recorded  (Gull,  Rodocalat,  Pitres).  Marce  records 
a  case  of  contusion  of  the  right  occipital  lobe,  followed  by  effusion  into  the 
membranes  and  softening  of  the  cortex,  without  any  sensory  or  motor 
disorders. 

In  a  case  reported  by  Sesti^  there  was  an  abscess  in  each  occipital 
lobe,  but  no  sensory  disturbances  were  present  during  life.  Charcot 
has  observed  cutaneous  formication  and  other  parsesthesiae  in  cases  of 
softening  of  the  occipital  lobes,  while  Hughlings-Jackson  and  Bastian 
believe  that  disease  of  the  posterior  lobes  is  more  frequently  associated 
with  mental  derangement  than  disease  of  other  parts  of  the  brain. 
Hughlings-Jackson  also  thinks  that  discharging  lesions  of  the  right 
occipital  lobe  are  more  apt  to  give  rise  to  coloured  vision  and  other 
ocular  spectra  than  disease  of  the  left  lobe.  Ferrier  quotes  the 
following  case  from  Abercrombie.  A  boy  suffered  from  an  injury  of 
the  head  causing  depression  of  a  considerable  portion  of  the  right 
parietal  bone,  the  depressed  portion  being  forced  through  the  dura  mater, 
and  driven  inwards  upon  the  brain.  He  had  paralysis  of  the  left  side 
and  amaurosis  of  the  left  eye.  On  the  depressed  portion  being  removed, 
the  paralysis  was  greatly  diminished,  and  the  eye  recovered  a  considerable 
degree  of  vision.  On  the  third  day  after  the  operation,  the  wound  in  the 
dura  mater  was  inflamed,  with  considerable  tumefaction,  and  immediately 
the  left  leg  and  arm  became  paralysed,  the  paralysis  being  preceded  by 


THE   LOCALISATION   OF   THE  LESION. 


635 


convulsions,  and  the  left  eye  again  became  amaurotic.  He  had  frequent 
convulsions  of  the  affected  extremities  for  several  days,  the  right  side  not 
being  in  the  least  affected,  when,  suppuration  having  taken  place,  all  the 
symptoms  subsided.  It  is  very  probable  that  the  depression  of  the  skull 
in  this  case  had  extended  beyond  the  motor  area  of  the  cortex  to  the 
angular  gyrus,  and  compression  of  the  latter  would  probably  sufl&ce  to 
explain  the  temporary  amaurosis  of  the  opposite  eye. 

It  has  been  stated  by  Bastian  that  vision  is  apt  to  be  impaired  on  the 
side  of  the  motor  paralysis  in  cases  of  thrombosis  of  the  posterior  cerebral 
artery.  Furstner  has  observed  unilateral  affections  of  sight  in  cases  of 
general  paralysis  of  the  insane  in  which  the  occipital  lobes  were  specially 
involved  in  the  disease.  A  most  important  case  in  this  connection  has 
been  reported  by  Glynn,  in  which  the  patient  became  suddenly  and 
completely  blind,  and  in  which  a  clot  was  found  occluding  the  posterior 
cerebral  artery  of  the  left  side,  causing  extensive  softening  of  the  left 
occipital  and  temporo-sphenoidal  lobes.  In  the  case  of  word-blindness 
observed  by  Broadbent,  and  which  we  have  already  reported  in  full,  the 
important  lesion  was  found  in  the  region  of  the  angular  gyrus  and  supra- 
marginal  lobule  {Fig.  267). 

Fig.  267.- 


Several  cases  are  mentioned  by  Nothnagel  in  which  disease  of  the  occi- 
pital lobe  was  associated  with  bilateral  hemianopsia,  but  in  most  of  these 
cases  the  disease  of  the  hemisphere  was  associated  with  an  affection  of 
the  optic  thalamus.  But  the  external  geniculate  body,  in  which  the  optic 
tract  terminates,  is  so  liable  to  be  implicated  in  lesions  of  the  optic 
thalamus  that  no  case  in  which  the  thalamus  is  extensively  involved 
along  with  the  occipital  lobe  possesses  any  value  for  the  determination  of 
this  question.  Even  large  tumours  of  the  occipital  lobe  which  might 
injure  the  external  geniculate  body  by  compression  do  not  afford  trust- 
worthy evidence.  In  a  case  described  by  Pooley,  there  was  paresis  of 
the  right  half  of  the  body,  diminished  sensibility  of  the  right  arm, 
and  a  sharply-defined  right-sided  hemianopsia  of  both  eyes.    A  tumour 


636  FOCAL  DISEASES,   ACCORDING  TO 

was  found  in  the  left  occipital  lobe ;  but,  in  addition,  the  left  optic 
thalamus  and  the  surrounding  cerebral  substance  were  completely 
softened.  Another  case  is  described  by  Hirschberg,  in  which  there 
were  aphasia,  right-sided  hemiparesis,  and  right-sided  hemianopsia. 
A  tumour  was  found  in  the  left  occipital  lobe,  surrounded  by  softened 
tissue,  which  extended  to  the  optic  thalamus.  It  is  difl&cult  to  under- 
stand how  the  external  geniculate  body  could  escape  being  diseased  in 
such  a  case.  Wernicke  reports  a  case  in  which  the  symptoms  consisted  of 
aphasia,  agraphia,  alexia,  and  right-sided  hemianopsia.  Extensive  softening 
was  found  in  the  convexity  of  the  left  hemisphere.  The  area  of  softening 
reached  posteriorly  2  cm.  behind  an  ideal  line  drawn  vertically  downwards 
from  the  parieto-occipital  fissure ;  superiorly,  it  was  limited  by  the  intra- 
parietal  sulcus ;  anteriorly,  it  extended  to  the  ascending  parietal  convo- 
lution above  the  Sylvian  fissure,  and  involved  the  superior  middle  temporo- 
sphenoidal  convolutions  below  it.  The  softening  penetrated  into  the  white 
substance  till  it  reached  the  ependyma  of  the  posterior  horn  of  the  lateral 
ventricle.  The  left  corpus  striatum — both  the  caudate  and  lenticular 
nuclei — was  softened ;  but  the  optic  thalamus,  the  geniculate  body,  the 
corpora  quadrigemina,  and  the  optic  tracts  were  normal.  Baumgarten 
mentions  a  case  observed  by  Jacobson  and  Jaffe,  in  which  the  left 
halves  of  the  fields  of  vision  became  suddenly  lost.  The  afiection  of  sight 
continued  unchanged  until  death,  which  occurred  a  few  months  later  from 
aortic  regurgitation.  An  apoplectic  cyst,  about  the  size  of  a  walnut,  was 
found  in  the  substance  of  the  right  occipital  lobe,  and  a  small  hsemor- 
rhagic  focus  in  the  centre  of  the  right  optic  thalamus.  Nothnagel  reports 
a  case  of  left  brachial  monoplegia,  with  right-sided  hemianopsia  of  both 
eyes.  The  autopsy  revealed  carcinoma  of  the  pancreas,  with  secondary 
deposits  in  the  liver  and  stomach.  The  right  hemisphere  presented  yellow 
softening  of  the  middle  third  of  the  ascending  frontal  and  parietal  con- 
volutions, which  penetrated  deeply  into  the  underlying  white  substance 
and  into  the  superior  parietal  lobule.  About  the  size  of  a  hazel-nut  of 
the  convolutions  on  each  side  of  the  intraparietal  sulcus  was  of  a  grey- 
yellow  colour,  while  the  softening  extended  in  the  imderlying  white  sub- 
stance down  to  the  wall  of  the  descending  horn  of  the  lateral  ventricle. 
The  third  occipital  convolution  of  the  right  hemisphere  was  also  softened. 
A  spot  of  red  softening,  about  the  size  of  a  hazel-nut,  was  observed  in  the 
right  optic  thalamus.  In  the  left  hemisphere  the  posterior  extremity  of 
the  second  frontal  convolution,  along  with  a  small  part  of  the  adjoining 
portion  of  the  ascending  frontal  convolution,  was  softened.  Another 
small  focus  of  softening  was  found  in  the  anterior  part  of  the  superior 
parietal  lobule,  while  the  whole  cortex  of  the  occipital  lobe  was  changed 
into  a  softened  mass  of  a  dirty  yellow  colour.  No  changes  were  observed 
in  the  optic  nerves  or  tracts.  Softening  was  observed  in  the  inferior  part 
of  the  cervical  enlargement  of  the  spinal  cord. 

Of  the  cases  just  mentioned  of  disease  of  the  occipital  lobes,  associated 
with  hemianopsia,  only  one  or  two  possess  real  value.     In  Pooley's  case, 


THE   LOCALISATION    OF   THE   LESION.  637 

the  left  optic  thalamus  and  surrouuding  cerebral  substance  is  described  as 
being  extensively  softened,  and  it  is  difficult  to  understand  how  the 
external  geniculate  body  could  .  escape  under  such  circumstances.  In 
Hirschberg's  case,  the  softening  which  surrounded  a  tumour  in  the  occi- 
pital lobes  extended  as  far  as  the  optic  thalamus  ;  and,  again,  the  external 
geniculate  body  would  be  very  liable  to  be  diseased.  Wernicke's  case  is, 
on  the  other  hand,  more  convincing,  but  even  in  it  the  corpus  striatum  is 
mentioned  as  being  softened.  It  is  not  contended  that  the  softening 
of  the  corpus  striatum  alone  would  account  for  the  hemianopsia  ;  but 
it  must  be  remembered  that  the  surcingle  of  the  caudate  nucleus 
passes  in  close  proximity  to  the  external  geniculate  body.  It  is, 
however,  mentioned  specially  that  the  geniculate  bodies  were  healthy 
in  this  case,  so  that  it  must  be  held  to  favour  the  idea  that  hemianopsia 
may  be  caused  by  disease  of  the  occipital  lobe.  Baumgarten's  case  also 
points  to  the  same  conclusion,  for  although  a  hsemorrhagic  focus  was 
found  in  the  centre  of  the  right  optic  thalamus,  yet  its  small  size  and  the 
position  it  occupied  renders  it  improbable  that  this  was  the  cause  of  the 
hemianopsia.  Nothnagel's  case  is  not  above  suspicion.  The  red  spot  in 
the  thalamus  probably  occurred,  as  the  author  asserts,  during  the  last 
stages  of  life,  and  could  not,  therefore,  have  caused  the  hemianopsia  ;  but 
the  lesions  observed  were  so  extensive  and  complicated  that  it  would  not 
be  safe  to  attach  much  importance  to  the  case.  Of  the  cases  just  de- 
scribed, those  of  Wernicke  and  Baumgarten,  and  in  a  less  degree  that  of 
Nothnagel,  are  the  only  ones  to  which  any  importance  need  be  attached 
as  indicating  that  bilateral  hemianopsia  may  result  from  disease  of  one  of 
the  occipital  lobes,  but  these  cases  can  only  be  regarded  as  affording  a 
presumption  in  favour  of  this  opinion.  It  is  right  to  add  that  Bellouard, 
who  has  written  an  admirable  monograph  on  the  subject  of  hemianopsia 
from  cerebral  disease,  believes  that  typical  bilateral  hemianopsia  may  be 
caused  by  disease  in  the  posterior  part  of  the  hemisphere  a  short  distance 
behind  the  radiations  of  Gratiolet's  fibres.  This  question  must,  therefore, 
be  left  for  future  observations  to  determine. 

Lesions  of  the  Temporo-sphenoidal  Lobe. — Lesions  of  the  temporo- 
sphenoidal  lobe  are  often  latent  as  regards  symptoms.  Charcot  and 
Pitres  report  a  case  which  presented  no  sensory  or  motor  disturbances 
during  life,  but  in  which  yellow  softening  was  found  after  death  in  the 
cortex  of  the  right  hemisphere.  The  diseased  area  occupied  the  posterior 
half  of  the  Island  of  Reil,  the  posterior  half  of  the  second  and  third  tem- 
poro-sphenoidal convolutions,  and  the  lower  two-thirds  of  the  inferior 
parietal  lobule.  Ferrier  places  the  auditory  centre  in  the  first  and 
second  temporo-sphenoidal  convolutions,  but  there  is  no  case  on  record 
in  which  disease  of  the  cortex  of  the  brain  has  given  rise  to  deafuess. 
The  reason  of  this  is  that  hearing  is  bilaterally  associated,  and  so  long  as 
one  hemisphere  is  unaffected  the  auditory  sense  remains  unimpaired  or 
only  slightly  weakened.  The  condition  already  described  as  word-deafness 
is,  however,  associated  with  disease  of  the  first  and  a  portion  of  the 


638 


FOCAL  DISEASES,   ACCORDING  TO 


second  temporo-sphenoidal  convolution.  In  a  case  of  this  kind  reported  by 
Wernicke  there  was  softening  from  thrombosis  of  the  first  and  a  large  por- 
tion of  the  second  temporo-sphenoidal  convolution  of  the  left  hemisphere 

Fig.  268. 


Fia.  269. 


{Fig.  268).  Dr.  Shuttleworth  reports  a  case  of  microcephalic  imbecility, 
in  which  hearing  was  dull  during  life,  and  at  the  autopsy  congenital  defi- 
ciency of  the  occipital  and  temporo-sphenoidal  lobes  was  found. 

The  case  of  a  woman,  aged  64  years, 
is  described  by  Pitres,  in  which  death 
occurred  a  few  hours  after  an  apoplec- 
tic attack.  Although  there  was  almost 
complete  loss  of  consciousness  from  the 
first,  there  was  no  paralysis  of  any  of 
the  limbs,  inasmuch  as  all  of  them 
were  moved  on  being  strongly  pinched. 
There  was  no  rotation  of  the  head  or 
deviation  of  the  eyes,  but  the  left  pupil 
was  more  dilated  than  the  right.  At 
the  autopsy  a  recent  heemorrhage  was 
found  occupying  the  whole  of  the  white 
substance  of  the  sphenoidal  lobe  {Fig. 
269).   The  basal  ganglia  were  healthy. 

Ferrier  found  that  destruction  of  the 
subiculum  cornu  Ammonis  causes  loss 
of  smell  on  the  same  side,  whi'e  in 
hemiancesthesia  from  disease  of  the 
posterior  fibres  of  the  posterior  seg- 
ment of  the  internal  capsule  the  loss 
of  smell  is  on  the  side  opposite  the  lesion.  As  already  described,  the 
olfactory  nerve  has  two  roots,  one  of  which  passes  directly  to  the  subicular 
region  of  the  same  side,  while  the  other  crosses  over  to  the  opposite  hemi- 


THE   LOCALISATION   OF   THE   LESION.  639 

sphere  through  the  anterior  commissure  of  the  third  ventricle.  It  is  not, 
therefore,  probable  that  unilateral  cortical  disease  will  cause  complete 
anosmia  of  one  nostril. 

The  anosmia  of  the  opposite  nostril,  the  result  of  disease  of  the  poste- 
rior fibres  of  the  internal  capsule,  is  caused  partly  by  the  loss  of  common 
sensation  in  the  nose,  from  severance  of  the  fifth  nerve  from  the  cortex, 
and  partly  by  destruction  of  the  fibres  of  the  internal  root  of  the 
olfactory  nerve.  Loss  of  smell,  either  alone  or  associated  with  dimi- 
nution of  taste,  not  unfrequently  results  from  blows  on  the  occiput  or 
vertex  of  the  head.  Dr.  Ogle  has  described  several  cases  of  this  kind, 
and  he  thinks  that  the  symptom  is  due  to  injury  of  the  olfactory  nerves, 
bulbs,  or  tracts  by  counterstroke.  When  the  occiput  receives  a  blow, 
the  skull,  being  elastic,  may  yield  without  fracture,  and  the  whole  of  the 
cerebral  mass  is  then  thrust  forwards  against  its  anterior  wall.  The 
temporo-sphenoidal  lobe  must  be  the  first  to  impinge  against  the  wings 
of  the  sphenoid  bone,  and  the  forward  movement  of  this  lobe  is  suddenly 
arrested,  while  the  upper  part  of  the  cerebrum  is  allowed  to  move  forwards 
until  it  is  arrested  by  the  frontal  bone.  It  is  evident  that  the  sudden 
arrest  of  the  temporo-sphenoidal  lobe  must  tend  to  rupture  the  roots  of 
the  olfactory  tract.  The  forward  movement  of  the  upper  portion  of  the 
cerebrum  will  also  tend  to  carry  with  it  the  olfactory  bulbs,  and  thus  to 
rupture  the  olfactory  nerves  as  they  pass  vertically  through  the  cribriform 
plate  of  the  ethmoid  bone. 

A  case  of  abscess  of  the  temporo-sphenoidal  lobe  is  reported  by  Dr. 
Glynn,  in  which  the  most  prominent  symptom  was  complete  anosmia. 
The  symptoms  consisted  of  noises  in,  and  partial  deafness  of  the  left  ear, 
amblyopia  and  dyschromatopsia  of  the  left  eye,  neuralgic  pains  over  the 
temporal  region  and  above  the  left  ear,  the  scalp  being  swollen  over  these 
regions,  a  crop  of  herpes  on  the  left  ala  nasi,  paresis  of  the  left  masseter, 
slight  facial  paralysis  of  the  left  side  of  the  body,  loss  of  taste  over 
the  left  half  of  the  tongue,  ptosis  of  left  eyelid  with  contraction  of  the 
pupil  on  that  side,  double  optic  neuritis,  complete  anosmia,  and  quasi 
hysterical  attacks.  At  the  post  mortem  a  circumscribed  abscess,  about 
two  inches  in  length,  was  found  situated  in  the  anterior  part  df  the  first 
temporo-sphenoidal  convolution,  and  extending  inwards  and  downwards 
towards  the  base  of  the  brain.  With  the  exception  of  the  anosmia,  the 
localising  symptoms  in  this  case  were  caused  by  compression  of  the  cranial 
nerves  at  the  base  of  the  brain  in  the  anterior  fossa  of  the  skull.  Dr. 
Glynn  appears  to  think  that  the  loss  of  smell  was  caused  oj  implication 
of  the  cortical  centre,  but  it  is  more  likely  to  have  been  caused  by  com- 
pression of  the  external  root  of  the  olfactory  tract  of  the  same  side  at  its 
point  of  entrance  into  the  temporo-sphenoidal  lobe  and  of  the  fibres 
which  cross  in  the  anterior  commissure  of  the  third  ventricle. 

Ferrier  localises  the  centre  of  tactile  sensibility  in  the  hippocampal 
region,  but  unilateral  lesions  of  the  hippocampal  convolutions  are  not 
known  to  produce  ansesthesia.     In  the  cases  of  disease  of  the  sphenoidal 


640  FOCAL   DISEASES,   ACCORDING   TO 

lobe,  in  which  there  was  loss  of  tactile  sensibility,  the  latter  was  most 
probably  caused  by  disease  of  the  sensory  fibres  of  the  internal  capsule. 
The  hippocampus  is  frequently  found  atrophied  in  epileptics  (Meynert), 
but  the  lesion  has  not  as  yet  been  connected  with  any  special  symptom. 

c.  Lesions  in  the  Area  of  Distribution  of  the  Anterior 
Cerebral  Artery. 

Lesions  in  the  prse-frontal  region  of  the  hemisphere  are  said 
to  be  latent,  although  it  would  be  more  correct  to  say  that  they 
do  not  give  rise  to  manifest  sensory  or  motor  disturbances. 

One  of  the  most  remarkable  cases  on  record  of  injury  to  the  frontal 
lobe  is  that  known  as  the  American  crowbar  case,  described  in  detail  by 
Ferrier.  An  iron  bar,  3ft.  7 in.  long  and  l;^in.  in  diameter,  and  weighing 
1 3 jibs.,  propelled  with  its  pointed  end  first  by  an  explosion  which  occurred 
during  blasting,  entered  at  the  left  angle  of  the  patient's  jaw,  and  passed 
through  the  top  of  his  head,  near  the  sagittal  suture  in  the  frontal  region. 
The  patient  was  for  a  monaent  stunned,  but  in  an  hour  afterwards  he  was 
able  to  walk  up  a  long  flight  of  stairs,  and  give  the  surgeon  an  intelligible 
account  of  his  injury.  He  recovered,  after  protracted  suffering,  and  lived 
upwards  of  twelve  years  afterwards.  But  although  the  injury  had  not 
left  permanent  traces  in  the  form  of  paralysis  or  sensory  disturbance^ 
this  man's  disposition  and  character  were  observed  to  have  undergone  a 
serious  change.  Dr.  Harlow,  who  reports  the  case,  says  :  "  His  em- 
ployers, who  regarded  him  as  the  most  efficient  foreman  in  their  employ 
previous  to  his  injury,  considered  the  change  in  his  mind  so  marked  that 
they  could  not  give  him  his  place  again.  He  is  fitful,  irreverent,  indulging 
at  times  in  the  grossest  profanity  (which  was  not  previously  his  custom), 
manifesting  but  little  deference  to  his  fellows,  impatient  of  restraint  or 
advice  when  it  conflicts  with  his  desires,  at  times  pertinaciously  obstinate, 
yet  capricious  and  vacillating,  devising  many  plans  of  future  operation, 
which  are  no  sooner  arranged  than  they  are  abandoned  in  turn  for  others 
appearing  more  feasible.  A  child  in  his  intellectual  capacity  and  mani- 
festations, he  has  the  animal  passions  of  a  strong  man."  Numerous 
cases  might  be  cited  of  injuries  and  lacerations  of 
the  frontal  lobes  from  gunshot  wounds  and  other 
accidents  without  any  very  manifest  permanent 
symptoms  being  produced  ;  but  the  reader  is  re- 
ferred for  the  details  of  such  cases  to  works  like 
those  of  Ferrier,  Grasset,  Nothnagel,  Pitres,  and 
Boyer,  which  are  specially  devoted  to  the  subject  of 
cerebral  localisation.  Several  cases  of  injury  of  the 
frontal  lobes  without  sensory  or  motor  affection  are 
collected  by  Pitres.  In  a  case  reported  by  Charcot 
and  Pitres,  a  man,  after  eating  a  large  quantity 


THE   LOCALISATION   OF   THE  LESION.  641 

of  fruit,  suflFered  from  repeated  vomiting,  and  died  two  days  subse- 
quently. There  was  no  trace  of  paralysis  of  the  face  or  upper  ex- 
tremities; and  although  there  was  permanent  contracture  of  the  lower 
extremities,  this  was  sufficiently  accounted  for  by  local  disease  of  the 
sciatic  nerves,  and  the  lumbar  enlargement  of  the  cord.  In  the  right 
hemisphere,  immediately  subjacent  to  the  anterior  extremity  of  the  second 
frontal  convolution,  a  haemorrhagic  focus  of  the  size  of  a  nut  was  found. 

Pitres  describes  several  cases  of  abscess  of  the  anterior  lobe  of  the 
brain,  in  which  there  was  entire  absence  of  paralytic  symptoms  during 
life.  In  a  case  of  abscess  of  the  anterior  lobe  of  the  right  hemisphere 
supervening  upon  injury  to  the  orbit,  which  came  under  my  observation, 
the  patient  lay  for  about  ten  days  in  a  somnolent  condition,  but  without 
manifesting  any  paralysis.  Two  days  before  death  slight  twitching  was 
observed  in  the  left  facial  muscles,  which,  in  the  course  of  some  hours, 
extended  to  the  arm.  Two  days  after  the  twitching  movements  began  the 
the  patient  had  a  general  convulsion,  became  comatose,  and  died  soon 
afterwards.  An  abscess  about  the  size  of  a  hen's  egg  was  found  in  the 
anterior  extremity  of  the  right  hemisphere.  The  motor  symptoms  which 
supervened  before  death  in  this  case  were  doubtless  due  to  an  extension 
of  encephalitis  around  the  primary  focus,  and  were  not,  therefore,  directly 
caused  by  the  presence  of  the  abscess. 

In  another  case,  which  came  under  my  observation,  the  patient 
lay  for  a  period  of  ten  days  in  a  somnolent  condition,  but  without 
presenting  any  paralysis  of  sensation  or  motion.  When  loudly  asked  a 
question,  the  patient  looked  up  and  gave  an  intelligent  answer,  but  imme- 
diately relapsed  into  the  same  somnolent  condition.  He  died  comatose, 
and  at  the  autopsy  a  haemorrhagic  focus  about  the  size  of  a  pigeon's  egg 
was  found  in  the  anterior  extremity  of  the  centrum  ovale  of  the  left 
hemisphere.  Congenital  deficiency  of  the  frontal  lobes  is  frequently 
observed  in  idiocy.  The  symptoms  which  characterised  the  cases  of 
disease  of  the  prse-frontal  regions  that  came  under  my  own  observation 
were  mental  torpidity  and,  towards  the  termination,  somnolency,  from 
which  the  patient  could  only  be  temporarily  aroused,  and  which  gra- 
dually increased  to  coma.  Dr.  Orichton  Browne  has  drawn  attention 
to  the  fact  that  during  the  early  stage  of  general  paralysis  of  the  insane, 
when  the  convolutions  of  the  frontal  lobe  are  particularly  apt  to  manifest 
degenerative  changes,  the  characteristic  symptoms  consist  of  "general 
restlessness  and  unsteadiness  of  mind,  with  impairment  of  attention, 
alternating  with  apathy  and  drowsiness."  Tumours  of  the  frontal  lobes 
which  spring  from  or  reach  their  inferior  surfaces  may  by  compress- 
ing the  nerves  which  pass  along  the  base  of  the  skull  give  rise  to 
aflfections  of  the  senses  of  smell  and  sight,  sensory  disturbances  in  the 
region  of  distribution  of  the  fifth  nerve,  or  paralysis  of  the  nerves  which 
pass  along  the  wall  of  the  cavernous  sinus  ;  but  cases  of  this  kind  will 
be  subsequently  considered.  Focal  lesions  of  the  prse-frontal  may  also 
by  extending  backwards  to  the  frontal  regions  occasionally  determine 
PP 


642  FOCAL   DISEASES. 

irritative  or  paralytic  disturbances,  the  muscles  of  tlie  face  and  neck  being 
first  implicated,  then  those  of  the  arm,  and  those  of  the  leg  last.  When 
lesions  of  the  prae-frontal  region  are  attended  by  active  delirium,  or  con- 
vulsions, it  is  probable  that  the  primary  focus  is  surrounded  by  a  more  or 
less  diffused  encephalitis,  or  at  least  by  a  zone  of  tissue  in  a  state  of  irri- 
tation, which  extends  to  the  cortex  of  the  motor  area.  The  characteristic 
features  of  lesions  in  the  prse-frontal  region  of  the  cortex  are  afforded  by 
the  psychical  disturbances,  consisting  of  dementia,  apathy,  and  somno- 
lency. When  convulsions  are  present,  they  are  not  preceded  by  an  aura, 
and  the  spasmodic  phenomena  are  of  short  duration,  while  the  stage  of 
insensibility  is  comparatively  prolonged. 


643 


CHAPTER   VIII. 


(II.)       SPECIAL     CONSIDERATION     OF     FOCAL     DISEASES, 
ACCORDING    TO   THE    LOCALISATION   OF  THE   LESION 

(Continued). 


3.    LESIONS   OF  THE  BASAL    GANGLIA,   EXTERNAL    CAPSULE, 
AND    CLAUSTRUM. 

Lesions  of  the  basal  ganglia  have  already  been  considered 
in  a  general  manner  along  with  the  affections  of  the  internal 
capsule,  and  little  remains  but  to  show  that  those  limited  to 
the  ganglia  themselves  do  not  give  rise  to  decided  symptoms 
during  life,  or  at  least  that  these  symptoms  are  not  of  an 
enduring  character. 

{a)  Lesions  of  the  Lenticular  Nucleus. 

§  751.  Several  cases  are  now  on  record  in  which  the  lenticular 
nucleus  had  been  found  at  the  autopsy  converted  into  a  cyst, 
containing  serous  fluid,  but  in  which  paralysis  of  the  opposite 
side  of  the  body  had  been  completely  absent  during  life  (Lupine, 
Charcot,  Nothnagel).  When  a  history  of  the  symptoms  can  be 
obtained  it  is  found  that  the  patient  had  some  months  or  years 
previously  suffered  from  an  attack  of  apoplexy,  followed  by 
temporary  hemiplegia.  The  patient,  however,  makes  a  good 
recovery,  and  the  cerebral  attack  from  which  he  suffered  may 
be  completely  forgotten,  so  that  the  lesion  of  the  lenticular 
nucleus  is  revealed  quite  unexpectedly  at  the  autopsy.  A 
woman,  aged  57  years,  suffering  from  tahes  dorsalis,  was  under 
the  observation  of  Nothnagel  for  six  months  before  her  death, 
during  which  time  she  had  no  cerebral  symptoms,  yet  a  diseased 
focus  was  found  in  the  posterior  and  inferior  angle  of  the  right 
lenticular  nucleus. 


644)  FOCAL  DISEASES,   ACCOI^DING  TO 

In  the  case  of  pseudo-bulbar  paralysis  already  described, 
which  came  under  my  own  observation,  both  lenticular  nuclei 
were  converted  into  cysts,  and  yet  there  was  no  paralysis  of  the 
extremities  during  life. 

Tumours  of  the  lenticular  nucleus  generally  give  rise  to 
hemiplegia  of  the  opposite  side,  the  paralysis  being  sometimes 
preceded  by  spasmodic  contractions.  Speech  was  affected  in 
six  out  of  sixteen  cases  of  tumours  of  the  lenticular  nucleus 
collected  by  Ladame,  but  the  size  of  the  tumours  in  some  of 
these  cases  precluded  the  idea  that  they  could  have  been 
limited  to  the  area  of  the  lenticular  nucleus.  In  two  cases 
there  was  difficulty  of  articulation,  in  three  slowness  of  speech, 
and  in  one  only  aphasia.  The  difficulty  of  articulation  pro- 
bably depended  upon  compression  of  the  geniculate  tract  of  the 
internal  capsule,  the  aphasia  upon  simultaneous  compression  of 
the  geniculate  fibres  and  those  of  the  corpus  callosum  which 
connect  the  posterior  extremities  of  the  third  frontal  convolu- 
tions with  one  another,  while  the  slowness  of  speech  might 
either  be  a  symptom  of  general  compression  of  the  brain  or  of 
special  compression  of  the  Island  of  Reil  and  the  posterior 
extremity  of  the  third  frontal  convolution.  A  large  tumour  of 
the  lenticular  nucleus  might  compress  the  optic  tract,  either 
at  its  origin  in  the  external  geniculate  nucleus,  or  as  it  winds 
round  the  crus  cerebri,  and  then  bilateral  hemianopsia  of  the 
opposite  side  would  be  present.  Tumours,  however,  which 
remain  limited  to  the  lenticular  nucleus  do  not  give  rise  to 
decided  paralysis. 

The  case  of  a  woman,  aged  30  years,  is  described  by  Fiirstner,  to  whom 
two  grammes  of  chloral  had  been  given  as  a  hypnotic  on  account  of 
puerperal  mania,  and  who  suffered  from  symptoms  of  chloral  poisoning. 
She  had  repeated  rigors,  lowering  of  the  temperature  of  the  body,  palpita- 
tion, and  acute  oedema  of  the  lungs.  For  some  days  she  complained  of 
general  weakness,  while  an  erythematous  eruption  appeared  over  the 
body,  and  a  bed-sore  over  the  sacrum.  Pneumonia  now  supervened,  and 
the  patient  died  seven  days  after  the  administration  of  the  chloral.  At 
the  autopsy,  besides  the  usual  signs  of  pneiunonia,  a  teleangiectatic  glioma 
was  found  symmetrically  placed  on  each  side,  and  occupying  the  position 
of  the  middle  and  internal  divisions  of  the  lenticular  nuclei,  the  third 
division  being  free  on  both  sides. 

Fiirstner  ascribes  the  feeling  of  general  feebleness,  of  which 


THE   LOCALISATION    OF   THE   LESION.  645 

the  patient  complained,  to  the  toxic  action  of  the  chloral ;  and 
even  supposing  that  this  feeling  was  a  bilateral  hemiparesis 
caused  by  the  tumours,  it  must  be  remembered  that  the  symp- 
tom only  appeared  a  week  before  death ;  besides  it  is  probable, 
from  the  position  of  the  tumours,  that  the  fibres  of  the  internal 
capsule  suffered  a  certain  amount  of  injury.  A  somewhat 
similar  case  is  described  by  Ron  dot. 

A  man,  aged  30  years,  complained  of  pains  in  the  neck  and  head,  and 
of  a  feeling  of  weakness  of  the  extremities,  but  was  able  to  walk  about. 
At  no  time  did  the  case  present  any  paralysis,  contractures,  or  sensory 
disturbances.  Death  occurred  somewhat  suddenly ;  and  at  the  autopsy 
two  tumours  were  found,  each  being  about  the  size  of  a  large  hazel-nut, 
and  symmetrically  placed  in  the  hemispheres.  A  transverse  vertical 
section  showed  that  each  tumour  occupied  the  position  of  the  lenticular 
nucleus ;  the  fibres  of  the  internal  caj)sule  were  compressed  and  laushed 
inwards,  while  the  cerebral  substance  was  softened  to  the  extent  of  three 
or  four  mm.  in  thickness  on  the  external  surfaces  of  the  tumours.  The 
tumours  were  dense  and  white,  though  their  peripheral  zones  were 
vascular. 

A  case  of  syphiloma  of  the  brain  has  been  observed  by 
Schiitz,  and  one  of  tubercular  tumour  by  Bramwell,  in  each  of 
which  the  tumour  occupied  the  position  of  almost  the  whole  of 
the  lenticular  nucleus  of  the  left  side,  and  in  neither  were 
there  symptoms  of  a  localised  cerebral  affection.  It  may, 
therefore,  be  laid  down,  as  a  general  rule,  that  acute  lesions 
limited  to  the  lenticular  nucleus  give  rise  to  a  transitory  hemi- 
plegia of  the  opposite  side,  while  this  symptom  may  be  entirely 
absent  in  chronic  stationary  lesions  and  slow-growing  tumours. 

(b)  Lesions  of  the  Caudate  Nucleus. 

§  752.  Lesions  of  the  caudate  nucleus  do  not,  any  more  than 
those  of  the  lenticular  nucleus,  give  rise  to  permanent  symp- 
toms during  life,  unless  the  internal  capsule  be  implicated. 
Small  cystic  cavities  and  foci  of  softening  are  frequently  found 
in  the  caudate  nucleus  at  a  post-mortem  examination,  in  the 
absence  of  all  history  of  cerebral  symptoms  during  life.  Other 
cases  are  reported  in  which  a  slight  hemiplegia  had  occurred 
during  life,  followed  by  a  speedy  recovery,  and  in  which  a  focal 
lesion  was  subsequently  found  in  the  caudate  nucleus. 

The    following    case    observed    by    myself   illustrates    the 


64()  FOCAL  DISEASES,  ACCORDING  TO 

symptoms   which  may   be  present   during   the   growth    of  a 
tumour  of  the  caudate  nucleus. 

Samuel  Holmes,  set.  7  years,  presented  himself  as  an  out-patient  at  the 
Southern  Hospital,  Manchester,  on  January  26th,  1.876. 

The  following  history  was  elicited  from  the  mother : — He  was  a  bright, 
intelligent,  and  healthy  boy  until  abovit  15  months  ago,  when  he  fell  from 
a  wall,  5  feet  high.  Soon  afterwards  he  complained  of  constant  headache, 
chiefly  confined  to  the  forehead.  The  top  of  the  head  was  so  sensitive 
that  combing  his  hair  caused  him  much  pain.  He  could  not  keep  still ; 
his  legs,  especially,  were  constantly  moving,  and  at  meal  times  he  was  in 
the  habit  of  knocking  the  table  with  his  right  hand,  as  if  from  impatience. 
About  nine  months  ago  the  mother  noticed  that  his  mouth  was  shghtly 
"  crooked,"  and  that  his  left  arm  hung  helplessly  by  his  side.  The  forearm 
was  twisted  so  that  the  palm  of  the  hand  was  directed  outwards  and  the 
thumb  backwards,  his  fingers  were  bent,  but  she  thinks  his  thumb  at 
first  was  held  straight  and  drawn  away  from  the  fingers.  After  some 
weeks,  however,  the  thumb  became  bent  inwards  under  the  index-finger, 
and  she  had  to  pare  the  nail  of  the  thumb  frequently  to  prevent  its  cutting 
the  skin  of  the  outside  of  the  middle  finger.  He  now  began  to  drag  the 
left  foot  in  walking,  and  the  forearm  was  gradually  drawn  up  behind  his 
back,  instead  of  hanging,  as  at  first,  by  his  side. 

The  mother  had  had  nine  of  a  family,  no  miscarriages  and  no  still-born 
children.  One  child  died  from  convulsions  during  teething ;  a  second  child, 
who  was  weakly  from  birth,  died  at  the  age  of  three  months ;  and  a  daughter 
has  suffered  for  the  last  two  years  from  white  swelling  of  the  knee. 

On  presenting  himself  at  the  hospital  he  was  a  well-made  and  fully- 
developed  boy  for  his  years.  His  head  was  large,  but  well-proportioned ; 
face  round  and  plump,  although  pallid ;  his  incisor  teeth  were  regular,  his 
nose  was  well  formed,  the  muscular  system  was  well  developed,  and  there 
was  abundance  of  subcutaneous  fat.  There  was  very  well-marked  left 
facial  paralysis,  so  that  the  left  corner  of  the  mouth  could  not  be  moved. 
Both  eyes  could  be  closed ;  the  pupils  were  large,  equal,  sensitive  to  light, 
and  there  was  no  afiection  of  the  special  senses.  The  left  elbow  was  kept 
a  little  behind  the  body,  and  2  inches  from  the  side ;  the  forearm  was  bent 
at  right  angles  to  the  arm,  and  drawn  behind  the  trunk ;  the  hand  was 
strongly  pronated ;  the  thumb  was  adducted,  and  the  second  phalanx 
flexed,  so  that  the  point  rested  against  the  second  phalanx  of  the  middle 
finger.  The  first  phalanges  of  the  fingers  were  extended  and  in  a  line 
with  the  metacarpal  bones,  and  the  second  and  third  phalanges  were 
flexed.  A  considerable  amount  of  muscular  rigidity  was  induced  on 
attempting  passive  motion  at  the  elbow  and  wrist  joints.  By  a  volun- 
tary effort  he  could  raise  his  elbow  to  nearly  the  level  of  the  shoulder, 
and  then  bring  the  upper  arm  slowly  forwards;  but  he  could  neither 
extend  the  forearm,  produce  supination,  nor  extend  the  fingers.  The  left 
leg  dragged  during  walking,  but  there  was  no  muscular  rigidity,  and  all 


THE   LOCALISATION   OF   THE   LESION.  647 

the  movements  of  the  leg  could  be  separately  performed.  The  electro- 
cutaneous  sensibility  of  the  left  half  of  the  body  was  increased,  especially 
over  the  back  of  the  left  hand,  and  the  left  half  of  the  face  and  side  of  the 
head.  The  slightest  touch  of  the  skin  over  the  vertex  of  the  head  to  the 
left  of  the  middle  line  caused  the  patient  to  wince,  and  the  cutaneous 
sensibility  to  pain  was  increased  over  the  left  half  of  the  body  generally. 
The  other  organs  appeared  to  be  healthy,  and  there  was  no  albumen  or 
sugar  in  the  urine.  He  was  ordered  four  grains  of  iodide  of  potassium 
three  times  a  day ;  but,  as  no  improvement  took  place,  he  was  admitted 
into  the  hospital  on  February  28th. 

March  10th,  1877. — He  was  ordered,  on  admission,  fifteen  minims  of 
the  syrup  of  the  iodide  of  iron,  to  be  taken  three  times  a  day,  and  the 
daily  application  of  a  weak  constant  current  to  the  paralysed  muscles  and 
nerves.  After  two  applications  of  the  constant  current  he  could  extend 
his  fingers  to  a  slight  extent,  and  in  a  few  days  he  was  able  to  raise  his 
hand  to  the  back  of  his  head.  It  was  observed,  however,  that  the  most 
marked  improvement  took  place  at  the  shoulder-joint ;  and  that  improve- 
ment in  the  movements  of  the  forearm  and  hand  was  only  to  a  shght 
extent.  This  improvement  was  of  short  duration,  and  he  now  looks 
decidedly  worse  than  on  admission.  The  pallor  of  the  face  is  much 
increased  ;  his  appetite  has  failed  ;  the  pulse  is  110,  weak  and  irregular  ; 
and  the  nurse  says  that  he  has  become  very  stupid.  Ordered  to  be  kept 
in  bed,  milk  diet  and  a  saline  mixture. 

March  18th. — Since  last  report  he  has  got  steadily  worse,  has  vomited 
frequently,  and  to-day  has  been  seized  with  general  convulsions.  The 
convulsions  frequently  recurred  during  the  next  two  days,  consciousness 
not  being  recovered  in  the  intervals,  and  he  died  early  on  March  21st. 

Sectio  cadaver  is,  twelve  hours  after  death. — On  opening  the  skull,  the 
convolutions  of  the  brain  presented  a  flattened  and  compressed  appearance, 
and  about  2  ounces  of  fluid  escaped  during  removal.  The  brain  weighed 
51  ounces.  On  slicing  the  brain  to  a  level  with  the  corpus  callosum  the 
upper  surface  of  a  tumour  was  exposed,  which  was  situated  in  the  centrum 
ovale  of  the  right  hemisphere,  immediately  to  the  right  of  the  corpus 
callosum  and  at  the  junction  of  the  anterior  and  middle  lobes.  On  opening 
the  lateral  ventricles,  this  tumour  was  felt  as  a  hard  nodule,  slightly  pro- 
jecting into  the  right  lateral  ventricle,  and  occupying  the  position  of 
the  caudate  nucleus  and  anterior  portion  of  the  optic  thalamus,  and  only 
covered  by  the  ependyma  of  the  ventricle.  The  tumour  measm-ed  three- 
quarters  of  an  inch  in  the  transverse  and  an  inch  in  the  antero-posterior 
and  vertical  diameters  respectively,  so  that  not  only  the  caudate  nucleus 
and  anterior  portion  of  the  optic  thalamus,  but  also  the  anterior  two-thirds 
of  the  internal  capsule  and  the  anterior  portion  of  the  lenticular  nucleus 
were  destroyed  by  it. 

The  growth  was  pretty  sharply  defined  from  the  surrounding  brain- 
tissue,  and  on  section  it  presented  an  outer  gpey,  somewhat  vascular  cortex, 
about  two  lines  thick,  and  a  central  core  of  a  yellow  colour,  and  apparently 
destitute  of  any  structm'e. 


648 


FOCAL   DISEASES,  ACCORDING  TO 


Microscopic  examination  showed  that  the  grey  cortex  of  the  tumour 
consisted  of  giant  cells,  each  surrounded  by  lymphoid  cells  imbedded  in  a 
iibrillated  reticulum. 

The  right  limg  was  closely  adherent  to  the  chest  wall  and  to  the 
diaphragm.  The  lung  itself  was  congested,  but  every  portion  of  it  floated 
in  water.  No  tubercles  nor  cheesy  glands  were  discovered,  and  the  other 
organs  were  healthy. 

•Fig.  271. 


M^J0&^ 


Fig.  271  (From  Flechsig).  Horizontal  Section  of  the  Brain  of  a  Child  nine  months 
of  age,  the  right  side  being  at  a  somewhat  lower  level  than  the  left  half.—  F,  Frontal, 
TS,  Temporo-sphenoidal,  and  O,  Occipital  lobes;  Op,  Operculum;  /ra,Jslandof 
Eeil ;  Cls,  Claustrum ;  /'",  Third  frontal  convolution ;  Th,  Optic  thalamus  ; 
NC,  Caudate  nucleus  ;  JVC,  Tail  of  caudate  nucleus  ;  LN,  Lenticular  nucleus  ; 
7,  //,  ///,  First,  second,  and  third  divisions  of  the  lenticular  nucleus ;  EK, 
External  capsule  ;  IK,  Posterior  division,  IK',  Anterior  division,  and  K,  Knee 
of  the  internal  capsule ;  ah,  ph.  Anterior  and  posterior  horns  respectively  of  the 
lateral  ventricles  ;  gcc.  Knee  of  the  corpus  callosum  ;  sp,  Splenium  ;  mc,  Middle 
commissure ;  /,  Fornix ;  si,  Septum  lucidum ;  a,  Cornu  Ammonis. 


THE  LOCALISATION   OF  THE  LESION.  649 

The  tumour  in  this  case  appeared  to  have  commenced  growing 
in  the  caudate  nucleus  {Fig.  271,  NG),  although  it  ultimately- 
extended  to  the  anterior  half  of  the  lenticular  nucleus  {Fig. 
271,  LN),  and  completely  destroyed  the  anterior  segment  of  the 
internal  capsule  {Fig.  271,  IK').  The  most  remarkable  feature 
about  the  symptoms  was  that  the  face  was  more  paralysed  than 
the  arm,  and  the  arm  than  the  leg,  this  being  the  order  in 
which  the  paralysis  might  be  expected  to  appear,  provided  pres- 
sure was  exerted  on  the  internal  capsule  from  before  back- 
wards. The  hypergesthesia  of  the  head  was  probably  caused 
by  irritation  of  the  posterior  fibres  of  the  internal  capsule. 

(c)  Lesions  of  the  Optic  Thalamus. 

§  753.  The  lesions  of  the  optic  thalamus  by  which  the  fibres 
of  the  internal  capsule  suffer  damage  have  already  been  con- 
sidered. Acute  lesions  of  the  thalamus  except  those  of  small 
size  are  associated  with  more  or  less  paralysis  of  the  opposite 
side  of  the  body,  but  unless  the  lesion  be  large  the  paralysis 
is  only  temporary,  and  it  is  probable  that  when  permanent 
paralysis  results  the  fibres  of  the  pyramidal  tract  are  always 
injured.  Lesions  of  the  thalamus  are  also  frequently  asso- 
ciated with  hemiansesthesia,  but  the  sensory  phenomena  are 
in  nearly  all  cases  caused  by  injury  of  the  sensory  peduncular 
tract  in  its  ascent  through  the  internal  capsule,  and  of  the 
optic  radiations  of  Gratiolet. 

Lesions  of  the  optic  thalamus  are  frequently  associated  with 
bilateral  hemianopsia  of  the  side  opposite  the  lesion.  When 
the  lesion  of  the  thalamus  is  of  the  nature  of  hsemorrhage  or 
softening,  the  hemianopsia  is  probably  caused  by  implication  of 
the  external  geniculate  body  in  the  diseased  focus ;  but  when 
the  lesion  is  a  tumour  of  the  thalamus,  the  defect  of  sight  is 
often  the  result  of  pressure  on  the  optic  tract  as  it  winds  round 
the  crus  cerebri, 

{d)  Lesions  of  the  Corpora  Quadrigemina. 
§  754.  Tumours  of  the   corpora  quadrigemina  are  of  rare 
occurrence.     Out  of  the  831  cases  of  intracranial  tumour  col- 
lected by  Ladame  only  two  were  situated  in  the  corpora  quad- 
rigemina.   Several  cases  of  disease  of  these  ganglia  have  been 


650  FOCAL  DISEASES,   ACCORDING  TO 

recorded  since,  but  in  the  majority  of  them  the  lesion  has  not 
been  strictly  limited  to  these  bodies.  The  more  usual  symptoms 
of  lesion  of  the  corpora  quadrigemina  are  disturbances  of 
muscular  co-ordination,  disorders  of  the  movements  of  the  eye- 
balls and  iris,  and  defects  of  vision. 

The  disturbances  of  muscular  co-ordination  consist  of  stag- 
gering and  difficulty  of  maintaining  the  erect  posture,  the 
symptoms  being  similar  to  those  caused  by  disease  of  the 
peduncles  of  the  cerebellum.  And,  indeed,  when  the  anato- 
mical relations  between  the  corpora  quadrigemina  and  the 
superior  peduncles  of  the  cerebellum  are  considered,  it  becomes 
doubtful  whether  these  motor  disturbances  ought  not  to  be 
attributed  to  implication  of  the  latter.  The  disturbances  in 
the  ocular  movements  are  generally  caused  by  paralysis  of 
individual  branches  of  the  oculo-motor  nerves ;  and  Nothnagel 
thinks  that  those  disorders  are  more  likely  to  occur  when  the 
posterior  pair  of  ganglia  are  diseased.  The  retino-pupillary 
reflex  is  also  abolished.  No  definite  statement  can  be  made 
with  regard  to  the  state  of  the  pupils.  When  the  anterior  pair 
are  affected,  blindness  is  apt  to  supervene  at  an  early  period 
of  the  affection,  and  often  precedes  the  development  of  optic 
neuritis  in  cases  of  tumour.  In  two  cases  of  tumour  of  the 
cerebellum  which  1  observed,  and  in  which  the  corpora  quadri- 
gemina were  secondarily  implicated,  blindness  was  an  early 
symptom,  and  was  complete  in  both  cases  before  the  secondary 
atrophy  of  the  discs  had  advanced  far,  although  not  before  the 
appearance  of  double  optic  neuritis. 

(e)  Lesions  of  the  Claustrum  and  External  Caijsule. 
§  755.  A  case  is  described  by  Brault  and  Beurmann  of  a  man, 
aged  71  years,  who  a  few  weeks  after  an  injury  had  an  apo- 
plectic attack.  On  the  following  day  there  was  slowness  of 
speech,  and  paralysis  of  the  right  half  of  the  body  including  the 
face.  Three  days  after  the  attack  speech  was  still  slow,  but  the 
facial  paralysis  had  disappeared,  and  the  paralysis  of  the  extremi- 
ties was  much  improved,  while  every  symptom  of  the  attack  had 
disappeared  six  days  from  its  onset.  A  few  days  subsequently 
the  patient  died  from  causes  unconnected  with  the  apoplectic 
attack,  and  the  left  claustrum  and  external  capsule  were  found 


THE   LOCALISATION   OF  THE  LESION.  651 

completely  destroyed  by  a  haemorrhagic  focus,  8  cc.  long,  2^  cc. 
in  depth,  and  only  2 — 3  mm.  broad.  The  hemiplegia  in  this 
case  was  doubtless  caused  by  a  temporary  slight  pressure  on 
the  fibres  of  the  internal  capsule,  while  the  affection  of  speech 
was  occasioned  probably  by  pressure  on  the  Island  of  Reil, 
but  none  of  the  symptoms  could  be  attributed  to  the  destruc- 
tion of  the  claustrura  and  external  capsule  themselves. 

(/)  Lesions  of  the  Base  of  the  Skull. 

(i.)   Anterior  FossiE  of  the  Skull. 

§  756.  Records  of  lesions  limited  to  the  anterior  fossae  of  the 
skull  are  not  numerous.  Disturbances  of  smell  are  not  unfre- 
quently  present  in  chronic  basal  meningitis,  but  the  lesion  almost 
always  extends  beyond  the  anterior  fossse,  and  gives  rise  to  com- 
plications. The  symptoms  caused  by  tumour  in  this  region  are 
variable,  but  the  most  trustworthy  is  afforded  by  compression 
of  the  olfactory  bulbs  or  tracts.  Several  cases  of  tumour  in  this 
region  have  been  collected  by  Longet,  of  which  the  following 
is  an  example  : — 

A  woman,  aged  59  years,  suflfered  from  recurrent  attacks  of  dizziness, 
feelings  of  formication,  and  numbness  of  the  left  half  of  the  face.  After  a 
period  of  four  years  she  began  to  suffer  from  epileptiform  convulsions, 
but  enjoyed  good  health  in  the  intervals.  A  year  later  the  patient  expe- 
rienced a  pecuHar  disorder  of  smell,  which  she  could  not  accurately 
describe,  immediately  before  each  attack  of  dizziness,  and  this  last  was 
followed  by  an  epileptiform  attack.  After  the  expiration  of  another 
year  the  disorder  of  smell  had  became  less  troublesome  and  finally  disap- 
frontal  headache,  loss  of  intelligence,  and  coma.  At  the  autopsy  a  can- 
peared.  The  terminal  symptoms  consisted  of  attacks  of  severe  dizziness, 
cerous  tumour  the  size  of  a  duck's  egg  was  found  in  the  anterior  lobe  of 
the  left  hemisphere,  lying  on  the  dura  mater  of  the  anterior  fossa,  and 
extending  from  the  lamina  cribrosa  to  the  olfactory  roots.  The  left 
olfactory  tract  was  completely  destroyed. 

(ii.)  Lesions  of  the  Middle  Foss^  of  the  Skull. 
§  757.  Diseases  situated  in  the  middle  fossse  of  the  skull  are 
liable  to  implicate  many  important  structures  as  the  olfactory 
nerves,  the  optic  commissure  and  tract,  as  well  as  the  third, 
fourth,  fifth,  sixth,  seventh,  and  eighth  nerves.  It  will  thus  be 
seen  that  lesions  of  this  fossa  must  give  rise  to  very  compli- 


652  FOCAL   DISEASES,  ACCORDING  TO 

cated  symptoms.  The  following  case  reported  by  Ziemssen 
illustrates  the  symptoms  caused  by  basal  meningitis,  mainly 
lipaited  to  the  pia  mater  and  lying  over  the  middle  fossa  of  the 
skull, 

A  man,  aged  33  years,  contracted  syphilis  in  1855,  and  suifered  from 
secondary  symptoms.  On  March  9th,  1856,  while  walking  on  the  street, 
he  suddenly  observed  double  vision,  associated  with  ptosis  of  the  left  eye- 
lid, both  symptoms  remaining  constant.  In  June  he  complained  of  intense 
headache,  the  mouth  was  drawn  to  the  left,  and  there  was  difficulty  of  arti- 
culation and  deglutition.  Great  general  weakness  gradually  developed,  so 
that  the  patient  could  not  stand  alone,  and  when  supported  by  two 
attendants  his  gait  was  staggering.  On  August  11th,  the  patient  was 
found  in  a  state  of  great  emaciation ;  there  was  inabihty  to  close  the  right 
eye,  owing  to  paralysis  of  the  lower  lid ;  while  the  upper  Hd  could  be  ener- 
getically moved,  the  right  eye  could  be  moved  upwards,  inwards,  and  down- 
wards, but  not  outwards,  and  only  slightly  outwards  and  downwards.  The 
pupil  was  contracted,  and  reacted  feebly  to  hght.  In  the  left  eye  there 
was  complete  ptosis,  and  the  eyeball  was  immovable.  The  pupil  was  dilated 
and  fixed.  Apart  from  diplopia,  vision  in  both  eyes  was  good.  The  right 
facial  nerve  was  completely  paralysed,  and  the  muscles  did  not  react  to 
the  faradic  current;  the  left  facial  muscles  reacted  feebly.  The  move- 
ments of  the  tongue  were  normal.  The  sensory  disturbances  in  the  region 
of  distribution  of  the  fifth  nerves,  and  the  senses  of  taste  and  smell, 
were  unaffected.  The  movements  of  both  the  lower  and  the  left  upper 
extremity  were  normal,  but  the  grasp  of  the  right  hand  was  feeble,  the 
power  of  moving  the  fingers  was  incomplete,  and  the  interossei  muscles  and 
those  of  the  ball  of  the  thumb  were  atrophied.  There  were  no  sensory  dis- 
turbances of  the  body  or  extremities.  In  this  case  the  right  facial,  left 
oculo-motor,  right  trochlear,  and  the  two  sixth  nerves  were  completely 
paralysed,  while  the  right  oculo-motor  and  left  facial  were  partially 
paralysed.  Death  took  place  on  August  9th  from  pulmonary  phthisis. 
The  pia  mater  corres^jonding  to  the  middle  lobes  was  thickened,  while  the 
diseased  area  extended  towards  the  optic  commissure.  The  pia  mater 
was  thickened  over  the  left  oculo-motor  nerve,  which  was  congested, 
in  some  parts  thickened  and  softened,  and  in  others  atrophied.  In 
the  thickened  parts  a  microscopic  examination  revealed  fine  fat  globules, 
without  a  trace  of  nerve  fibres.  The  right  facial  and  trochlear  nerves  were 
altered  in  the  same  manner  as  the  left  oculo-motor.  A  certain  degree  of 
thickening  was  found  at  the  origin  of  the  right  oculo-motor  nerve ;  but  a 
microscopic  examination  revealed,  besides  fat  globules,  healthy  nerve  fibres. 
The  left  facial  and  the  two  acoustic  nerves  presented  morbid  appear- 
ances similar  to  those  found  in  the  right  oculo-motor  nerve.  Both  the 
sixth  nerves  were  flattened.  The  olfactory,  optic,  trigeminal,  hypo- 
glossal, spinal  accessory,  glosso-pharyngeal,  and  pneumogastric  nerves  were 
normal.     The  brain  was  healthy. 


THE   LOCALISATION    OF   THE   LESION.  653 

The  changes  in  this  case  extended  beyond  the  middle  fossae 
of  the  skull,  inasmuch  as  the  facial  and  acoustic  nerves  were 
implicated  in  the  disease,  but  it  nevertheless  affords  a  good 
example  of  the  symptoms  caused  by  a  chronic  basal  meningitis. 
In  a  patient  under  the  care  of  Dr.  Simpson,  sent  to  the  Cheadle 
Convalescent  Hospital  a  few  months  ago,  the  following  were 
the  leading  symptoms  observed: — 

A  man,  aged  49  years,  suffered  for  some  time  from  headache  and 
blindness  of  the  right  eye.  When  I  examined  him  in  July,  1880,  there 
was  complete  blindness  of  the  right  eye,  with  atrophy  of  the  optic  disc, 

Fig.  272. 


!PlG.  272  (From  Landois'  "  Physiologie  "). — Schema  of  the  semi-decussation  of  the 
fibres  of  the  Optic  Commissure ;  6  a.  Left  Optic  Tract,  the  fibres  of  which  are 
distributed  to  the  left  halves  of  both  retinas ;  a'  b',  the  Right  Tract,  with  its 
fibres  supplying  the  right  halves  of  both  retinas. 

complete  immobility  of  the  eyeball,  ptosis,  and  exophthalmos  from  para- 
lysis of  all  the  ocular  motor  nerves.  Vision  was  good  in  the  left  eye,  the 
field  of  vision  in  it  was  not  restricted,  and  there  were  no  changes  in  the 
optic  disc.  The  patient  had  suffered  for  some  time  from  neuralgic  pains 
in  the  region  of  distribution  of  the  first  and  second  division  of  the  fifth 
nerve,  and  at  the  time  of  examination  the  sensibility  of  this  region  was 
blunted  but  not  abolished.  A  tenacious  secretion  covered  the  right  eye- 
ball, but  the  cornea  was  not  cloudy.  The  right  masseter  muscle  was  feeble 
and  decidedly  atrophied  in  comparison  with  the  corresponding  muscle  on 
the  left.  The  man  died  two  weeks  after  my  visit,  and  at  the  autopsy 
Dr.  Massiah  found  the  right  optic  nerve  close  to  the  foramen,  surrounded 
by  a  ring  of  dense,  apparently  cicatricial,  tissue.  This  thickened  tissue, 
which  did  not  form  a  distinct  tumour,  had  extended  backwards  above 
the  cavernous  sinus  and  spread  over  the  Gasserian  ganglion  and  motor 
root  of  the  fifth  nerve.  The  right  optic  tract  {Fig.  272,  a'  b')  was  un- 
affected. 

Tumours  of  the  middle  fossa  of  the  skull  generally  give  rise 


654  FOCAL   DISEASES,  ACCORDING  TO 

to  still  more  definite  symptoms.  The  symptoms  in  the  following 
case,  under  the  care  of  Dr.  Dreschfeld,  deserve  to  be  compared 
with  those  of  the  case  which  has  just  been  described. 

A  man,  aged  40  years,  suflfered  for  some  time  from  symptoms  of  cere- 
bral disease.  For  some  weeks  before  bis  deatb  bis  symptoms  were  bUndness 
of  tbe  right  eye  witb  atrophy  of  the  disc,  ptosis,  immobility  of  the  eyeball, 
and  paralytic  exophthalmos  of  the  right  eye ;  after  a  time  neuro-paralytic 
ophthalmia  of  the  same,  right  facial  prosopalgia,  optic  neuritis  of  left  disc, 
with  temporal  hemianopsia  of  the  left  eye,  and  polyuria.  The  post-mortem 
was  conducted  by  myself.  I  found  a  sarcomatous  tumour  lying  close  to 
the  right  optic  foramen,  and  compressing  the  optic  nerve ;  it  extended 
backwards  over  the  cavernous  sinus,  and  compressed  all  the  nerves  lying 
in  its  walls,  and  likewise  the  right  optic  tract  {Fig.  272,  a'  h'). 

Most  of  the  symptoms  in  this  case  were  so  definite  that  they 
scarcely  require  a  word  of  explanation.  The  blindness  of  the 
right  eye  and  atrophy  of  the  disc  were  caused  by  the  injury  of 
the  optic  nerve  at  its  point  of  entrance  into  the  optic  foramen, 
the  temporal  hemianopsia  of  the  left  eye  by  compression  of  the 
right  optic  tract,  the  optic  neuritis  of  that  eye  was  the  usual 
form  indicative  of  the  presence  of  an  intracranial  tumour, 
while  the  paralysis  of  all  the  ocular  muscles  was  caused  by 
compression  of  the  third,  fourth,  and  sixth  nerves  as  they  pass 
along  the  wall  of  the  cavernous  sinus.  The  polyuria  present 
in  this  case  is  nut  an  unfrequent  symptom  of  tumours  in  the 
neighbourhood  of  the  pituitary  body,  and  glycosuria  is  some- 
times observed  in  such  cases. 

AneurisTYi  of  the  internal  carotid  artery  at  the  base  of  the 
skull  does  not  appear  to  give  rise  to  any  characteristic  symptoms, 
and  auscultation  of  the  cranium  has  not  proved  of  much  service. 
Besides  a  constantly  recurring  and  distressing  headache,  the 
more  usual  symptoms  of  aneurism  of  the  internal  carotid  at  the 
base  of  the  skull  are  unilateral  or  bilateral  disturbances  of 
vision  from  compression  of  the  optic  tract  or  nerve,  spasms  soon 
followed  by  paralysis  of  the  ocular  muscles,  hyperaesthesia,  and 
neuralgia,  followed  by  anaesthesia  in  the  region  of  distribution 
of  the  fifth  nerve  and  great  mental  disturbances.  Paralysis  of 
the  extremities  of  the  opposite  side  may  occasionally  occur  from 
compression  of  the  pyramidal  tract  on  its  way  through  the 
crusta. 


THE   LOCALISATION   OF   THE   LESION.  655 

(iii,)     H^MOERHAGK  INTO  THE  LATERAL  VENTRICLES, 

§  758.  Haemorrhage  into  the  ventricles  is  followed  by  deep 
coma,  and  the  majority  of  patients  die  in  the  course  of  the  first 
or  second  day ;  although  occasionally  they  may  live  for  several 
days.  Haemorrhage  into  the  lateral  ventricles  constitutes  the 
majority  of  those  cases  which  have  been  called  ingravescent 
apoplexy,  but  some  of  these  are  caused  by  a  large  haemorrhage 
into  the  centrum  ovale,  or  on  to  the  surface  of  the  brain 
from  the  bursting  of  an  aneurism.  When  rupture  into  the 
lateral  ventricle  takes  place  the  corpus  callosum  and  fornix 
become  partially  destroyed,  and  the  haemorrhage  makes  its 
way  into  the  third  ventricle  and  into  the  lateral  ventricle  of 
the  opposite  side,  and  passes  through  the  aqueduct  of  Sylvius 
to  the  fourth  ventricle.  The  first  stage  of  haemorrhage  into  the 
ventricle  may  consist  of  ordinary  hemiplegia,  commencing  with 
an  apoplectiform,  epileptiform,  or  simple  mode  of  onset.  In- 
deed, the  simple  mode  of  onset  is  not  an  unusual  one,  since 
the  haemorrhage  frequently  begins  in  the  head  of  the  caudate 
nucleus,  lenticular  nucleus,  or  optic  thalamus,  and  the  primary 
symptoms  produced  are  not  well  marked.  But  whenever  the  brain 
substance  is  ruptured,  so  that  blood  is  poured  in  considerable 
quantity  into  the  lateral  ventricle,  a  severe  apoplectic  attack 
occurs,  characterised  by  profound  coma,  geneol  paralysis  of  the 
limbs,  and  dilated  pupils.  The  rectal  temperature  sinks  several 
degrees,  and  remains  depressed  for  several  hours ;  but  if  a  fatal 
result  do  not  speedily  occur  the  initial  depression  is  followed 
by  a  rapid  rise,  which  continues,  in  cases  about  to  prove  fatal, 
till  the  death  of  the  patient.  Haemorrhage  into  the  lateral  ven- 
tricle is  frequently  attended  with  a  spasmodic  contraction  of 
the  extremities  of  the  opposite  side,  which  may  be  either  tem- 
porary or  persist  until  death. 

(iv.)  Tumours  in  the  neighbourhood  of  the  Pituitary  Body, 
§  759.  Tumours  of  the  pituitary  body  are  usually  of  large 
size.  They  produce  compression  of  the  anterior  perforated 
space,  the  olfactory  tracts,  optic  commissures  and  roots  of  the 
optic  nerves,  the  corpora  albicantia,  the  posterior  perforated 
space,  and  when  the  tumour  is  large  the  pons  and  peduncles  of 


658 


FOCAL  DISEASES,   ACCOEDING  TO 


Fig.  273. 


Pig.  273  (From  Henle's  "  Anatomie").  ^Phe  Base  of  the  Brain  and  admining  part 
of  the  Spinal  Cord.— The  Cranial  Nerves  are  represented  by  the  corresponding 
Koman  letters  from  I  to  Xll.  VII',  Portio  intermedia  of  the  seventhj  nc  I, 
First  cervical  nerve. 


THE   LOCALISATION   OF   THE   LESION. 
Fig.  274. 


657 


Fig.  274  (From  Henle's  "Anatomie").  Internal  View  of  the  Base  of  the  Skull, 
showing  the  Places  of  Exit  of  the  Cranial  Nerves.  -The  Nerves  are  represented 
by  the  corresponding  Eoman  numerals,  from  I  to  XII.  V,  V^,  V^,  the 
first,  second,  and  third  divisions  of  the  fifth  respectively.  V*,  the  Gasserian 
Ganglion.  The  sensory  root  is  cut  short  in  order  to  show  the  motor  root  of 
the  fifth  as  it  passes  under  the  ganglion.  The  dura  mater  is  removed  on  the 
right  side,  and  the  nerves  may  be  followed  to  the  various  foramina  through 
which  they  pass  from  the  skull.  The  Nerves  III,  IV,  V^  and  VI  may  be 
seen  passing  over  the  convexity  of  the  curve,  which  the  internal  carotid  artery 
makes  in  the  groove  of  the  sphenoid  bone.  1,  Anterior  clinoid  process  ; 
2,  Posterior  clinoid  process  ;  3,  Transverse  section  of  the  internal  carotid 
artery.  H,  Peduncle  of  the  pituitary  body  ;  t,  anterior  body  of  the  divided 
tentorium  ;  fcb,  Falx  Cerebelli. 

QQ 


658  FOCAL   DISEASES,   ACCORDING  TO 

the  cerebellum  may  be  pressed  upon  and  flattened.  They  may 
also  encroach  upon  the  cavernous  sinuses  and  sphenoidal  fissures 
and  the  nerves  which  pass  through  them,  while  the  ventricles 
are  not  unfrequently  distorted  or  obliterated.  These  tumours 
are  also  very  liable  to  cause  softening  of  the  surrounding 
cerebral  tissue,  which  may  extend  to  the  basal  ganglia  or  the 
centrum  ovale. 

Periodical  headache,  usually  situated  in  the  frontal  and  tem- 
poral regions  and  extending  forwards  to  one  of  the  eyeballs  and 
supra-orbital  region,  is  one  of  the  earliest  symptoms  of  tumour 
in  the  neighbourhood  of  the  pituitary  body.  Blindness  occurs 
at  an  early  period  of  the  growth  of  these  tumours,  owing  to 
their  proximity  to  the  optic  commissure.  It  is  important  to 
remember  that  pressure  on  the  optic  commissure  or  nerves  causes 
secondary  atrophy  of  the  discs  without  being  preceded  by  the 
"  choked  disc." 

There  may  also  be  unilateral  or  bilateral  anosmia  due  to 
injury  of  the  olfactory  tracts.  When  the  tumour  exercises 
pressure  on  the  cavernous  sinuses,  incomplete  or  complete  para- 
lysis of  the  motor  nerves  of  the  eye  supervenes  on  one  or  both 
sides. 

Disorders  of  cutaneous  sensibility  are  rare  and  generally  of 
a  transitory  nature.  If  the  tumour  be  large,  one  or  more  of 
the  branches  of  the  fifth  nerve  on  one  or  both  sides  is  first 
irritated  and  then  compressed.  When  a  large  tumour  com- 
presses the  cerebral  peduncles  and  interpeduncular  space,  spas- 
modic contractions  of  the  muscles  of  the  extremities,  followed 
by  hemiplegia  or  paraplegia,  may  supervene. 

Two  other  interesting  symptoms  are  sometimes  associated 
with  tumours  in  the  vicinity  of  the  pituitary  body,  the  one  being 
accumulation  of  fat  in  the  subcutaneous  tissue,  and  the  other 
diabetes.  In  a  case  reported  by  Mohr,  as  quoted  by  Ladame, 
the  patient,  who  subsequently  died  from  tumour  of  the  pituitary 
body,  had  become  very  fat  before  death  ;  and  in  a  case  under 
the  care  of  Dr.  Simpson,  in  which  the  symptoms,  consisting 
mainly  of  paroxysmal  headaches  and  blindness,  with  simple 
white  atrophy  of  both  discs,  pointed  to  the  presence  of  a  tumour 
in  this  neighbourhood,  the  patient  became  very  fat  after  her 
illness.     During  her  residence  at  the  Manchester  Royal  In- 


THE   LOCALISATION   OF   THE   LESION.  659 

iirmary  she  was  passing  a  considerable  quantity  of  pale  urine, 
being  only  1004  in  specific  gravity.  In  a  case  of  tumour  of 
the  pituitary  body  reported  by  Rosenthal  the  patient  voided 
from  81bs,  to  lOlbs.  daily,  the  specific  gravity  was  from  1038 
to  1040,  and  the  urine  contained  a  large  quantity  of  sugar. 
Rosenthal  conjectures  that  in  cases  of  this  kind  the  grey  matter 
lining  the  third  ventricle  is  first  irritated,  and  that  the  irrita- 
tion travels  along  the  aqueduct  of  Sylvius  to  the  floor  of  the 
fourth  ventricle. 

The  following  case  is  a  good  example  of  the  symptoms  caused 
by  tumours  in  the  neighbourhood  of  the  pituitary  body,  and 
possesses  a  melancholy  interest,  inasmuch  as  a  respected 
member  of  the  medical  profession  was  the  victim  of  the 
disease  :  — 

Mr.  R ,  about  34  years  of  age,  consulted  rae  on  May  lOth,  1878. 

He  had  suffered  for  some  time  from  frequently  recurring  attacks  of  "  faint- 
ness  "  and  a  peculiar  defect  of  vision.  He  is  a  tall,  dark  man,  of  healthy 
appearance,  there  is  a  slight  depression  in  the  right  frontal  bone,  caused  by 
a  blow  received  in  childhood,  but  he  does  not  appear  to  have  suiiered  any 
inconvenience  from  it.  During  the  fainting  attacks,  one  of  which  I  had  an 
opxjortunity  of  observing,  there  is  pallor  of  the  face,  the  pulse  beats  from 
130  to  140  in  the  minute,  and  the  patient  looks  agitated,  but  there  is  no 
loss  of  consciousness.  The  duration  of  the  attack  is  only  about  half  a 
minute.  On  examining  his  eyesight  he  is  found  to  be  suffering  from  double 
temporal  hemianopsia,  the  inner  halves  of  the  retinse  being  bhnd.  The 
optic  discs  are  perfectly  normal,  this  opinion  being  confirmed  by  Mr. 
Windsor. 

February  7,  1879.  The  general  symptoms  continue  unchanged,  but  the 
fainting  attacks  are  now  accompanied  by  temporary  loss  of  consciousness. 
The  patient  is  now  blind  on  the  right  eye,  while  there  is  temporal  hemi- 
anopsia of  the  left.  Dr.  Little,  who  made  an  ophthalmoscopic  examination, 
reports  white  atrophy  of  the  right  and  incipient  atrophy  of  the  left 
optic  disc.  The  urine  is  abundant,  pale,  and  of  low  specific  gravity,  but 
does  not  contain  albumen  or  sugar.  The  only  psychical  disturbance  ob- 
served was  a  marked  and  not  unnatural  tendency  to  brood  over  his  own 
feeUngs  and  symptoms. 

The  diagnosis  in  this  case  presented  no  great  difficulty.  It 
was  manifest  that  a  tumour  at  the  base  of  the  skull  was  grow- 
ing in  such  a  way  as  to  compress  the  centre  of  the  chiasma  at 
first,  and  that  it  subsequently  extended  to  the  right  so  as  to 
have  compressed  the  right  optic  nerve.     I  saw  the  patient  two 


660  FOCAL   DISEASES. 

or  three  times  subsequent  to  the  last  report,  but  his  symptoms 
remained  unchanged.  For  the  following  report  of  the  progress 
and  termination  of  the  case  I  am  indebted  to  Dr.  M'Fie,  of 
Bolton. 

On  the  evening  of  July  3rd,  Mr.  R was  suddenly  attacked  with 

vomiting,  followed  by  an  epileptiform  seizure,  both  symptoms  recurring 
frequently  during  a  period  of  an  hour  and  a  half.  During  the  convulsive 
attacks  the  spasms  were  more  pronounced  on  the  left  than  on  the  right 
side.  During  that  night  the  patient  lay  in  a  semi-comatose  condition, 
but  he  gradually  regained  consciousness  on  the  following  day.  It  was 
now  noticed  that  the  left  side  of  the  face  was  paralysed,  and  that  there 
was  some  degree  of  paresis  of  the  left  extremities. 

August  30.  Since  last  report  the  patient  recovered  the  use  of  his 
limbs,  and,  although  he  has  suffered  from  occasional  attacks  of  sickness, 
he  has  walked  about  the  garden  as  usual.  This  evening,  however,  he  has 
had  another  epileptiform  seizure. 

September  10,  Since  last  report  the  patient  has  been  downstairs  and 
walking  about  the  garden,  but  after  partaking  of  his  usual  breakfast  this 
morning  he  became  somewhat  suddenly  insensible,  and  died  comatose  at 
night.     His  temperature  immediately  before  death  was  106°  F. 

At  the  post-mortem  examination  the  membranes  of  the  brain  over  the 
convexity  were  found  normal.  The  inner  table  of  the  skull  and  dura 
mater  were  normal  at  the  point  corresponding  to  the  external  depression 
of  the  right  frontal  bone.  The  substance  of  the  brain  was  observed  to  be 
bulged  between  the  frontal  and  parietal  lobes  in  the  right  hemisphere. 
On  removing  the  brain  a  lobulated  tumour  was  observed  lying  to  the  right 
side  of  the  optic  commissure ;  the  right  optic  nerve  was  compressed  by  it, 
but  the  left  nerve  occupied  its  usual  jposition,  and  did  not  appear  much 
altered.  The  tumour  sprang  from  that  portion  of  the  dura  mater  which 
covers  the  body  and  basilar  process  of  the  sphenoid  bone,  the  body  of  the 
bone  being  eroded  by  the  growth.  The  orbital  surface  of  the  frontal 
lobe  of  the  right  hemisphere  presented  a  deep  excavation  corresponding 
to  the  projection  of  the  tumoiu',  and  the  nervous  tissues  in  the  vicinity 
of  the  growth  were  somewhat  softened.  The  tumour  was  multilobulated 
and  of  the  colour  of  liver. 


661 


CHAPTER    IX. 


(II.)       SPECIAL     CONSIDERATION     OF     FOCAL     DISEASES, 
ACCOEDING  TO   THE  LOCALISATION  OF   THE   LESION 

(Continued). 


4.    LESIONS    LOCALISED    IN   THE    STRUCTURES   SITUATED 
BELOW   THE    TENTORIUM. 

a.  Lesions  in  the  Pons  and  Peduncles  of  the  Cerebrum. 
(i.)  Lesions  in  the  Pons. 

§  760.  HcdTnoi^'^hage  into  the  Pons. — If  the  hgemorrhage  be 
of  large  size,  profound  apoplexy,  with  flapping  of  the  cheeks 
during  expiration,  insensibility  of  the  conjunctivse,  and  strongly 
contracted  pupils  is  produced.  If  the  haimorrhage  extend 
upwards  to  the  grey  matter  beneath  the  aqueduct  of  Sylvius, 
the  ocular  muscles  may  be  paralysed,  and  the  pupils  dilated 
and  fixed.  Death  occasionally  takes  place  in  a  few  minutes 
or  in  a  few  hours,  although  life  may  be  prolonged  for  a  day 
or  two.  Bursting  of  the  hgemorrhage  into  the  fourth  ven- 
tricle is  generally  attended  by  convulsions,  although  convul- 
sions may  occasionally  occur  independently  of  this  accident.  If 
the  patient  recover  from  the  shock  of  a  central  hsemorrhage 
into  the  pons,  consciousness  is  gradually  regained,  but  it  is 
found  that  all  the  extremities  are  paralysed,  while  cutaneous 
sensibility  may  be  more  or  less  impaired.  Double  facial  paralysis 
involving  the  muscles  of  the  eyelids,  as  well  as  those  of  the 
mouth,  may  be  present,  both  sides  of  the  tongue  are  also  para- 
lysed, while  the  patient  experiences  difficulty  in  deglutition, 
there  is  a  copious  flow  of  saliva  from  the  paralysed  side  of  the 
mouth,  and  the  power  of  articulation  is  impaired. 

If  the  lesion  be  situated  in  the  lower  part  of  the  lateral  half 
of  the  pons,  the  symptoms  may  present  the  appearances  charac- 
teristic of  what  Gubler  has  called  alternate  hemiplegia.     There 


662 


FOCAL  DISEASES,   ACCOEDING  TO 


Fig.  275. 


is  well  marked  facial  paralysis  on  the  side  of  the  lesion,  and  a 
more  or  less  complete  motor  and  sensory  paralysis  of  the  limbs 
on  the  opposite  side. 

If  the  upper  part  of  the  lateral 
half  of  the  pons  be  the  seat  of  the 
lesion,  the  facial  paralysis  is  on  the 
same  side  as  the  paralysis  of  the  ex- 
tremities. In  order  to  account  for 
these  phenomena  it  is  necessary  to 
assume  that  the  fibres  of  the  pyra- 
midal tract,  which  connect  the  cortex 
of  the  opposite  hemisphere  with  the 
nucleus  of  the  facial  nerve  in  the 
upper  part  of  the  medulla,  cross  over 
about  the  middle  of  the  pons,  as  re- 
presented in  the  annexed  figure. 

Conjugate  deviation  of  the  eyes, 
with  rotation  of  the  head  and  neck, 
is  a  symptom  of  paralysis  of  the 
pons,  but  the  rule  with  regard  to 
the  direction  in  which  the  rotation 
takes  place  is  the  converse  of  that 
which  applies  to  lesions  of  the  hemi- 
spheres. When  the  lesion  is  situated 
in  the  hemispheres,  the  head  and 
eyes  are  turned  towards  the  affected 
limbs  during  convulsions,  and  towards  the  side  of  the  lesion  in 
paralysis ;  but  in  lesions  of  one  lateral  half  of  the  pons  the 
head  is  turned  towards  the  side  of  the  lesion,  if  the  limbs  be 
convulsed,  and  towards  the  affected  limbs  when  they  are 
paralysed  (Grasset). 

Early  rigidity  of  the  muscles  of  the  paralysed  extremities, 
the  masticatory  muscles,  and  those  of  the  neck,  is  often  observed 
in  lesions  of  the  pons. 

Disturbances  of  cutaneous  sensibility  are  frequently  met  with 
in  lesions  of  the  pons,  which  become  more  profound  and  definite 
as  the  lesion  approaches  the  upper  or  anterior  end  of  the  pons 
near  the  crusta.  The  sensory  disturbances  generally  consist 
of    anaesthesia,   although   unilateral   hypersesthesia   has   occa- 


FiG.  275  (From  Nothnagel). 

L,  Left. 

iJ,  Eight. 

P,  Pons. 
Mo,  Medulla  oblongata. 
DP,  Decussatio  pyramidum. 

E,  Nerve  fibres  for  the  extremi- 

ties. 

F,  Fibres  destined  for  the  facial 

nerve. 
X,  Lesion  in  the  upper  part  of 

the  pons. 
y.  Lesion  in  the  lower  part  of 

the  pons. 


k 


THE   LOCALISATION   OF   THE   LESION,  663 

sionally  been  observed,  and  either  condition  may  be  accom- 
panied by  painful  sensations  in  the  limbs,  or  by  a  subjective 
feeling  of  coldness,  even  when  the  temperature  of  the  part  is 
higher  than  natural.  Implication  of  the  fifth  nerve  gives  rise 
to  anaesthesia,  hypersesthesia,  parsesthesise,  or  painful  sensations 
in  the  region  of  distribution  of  the  nerve,  as  well  as  to  partial 
impairment  or  perversion  of  taste  on  the  side  of  the  lesion.  The 
masticatory  muscles  are  often  weakened  or  completely  paralysed 
on  the  side  of  the  lesion.  Acute  lesions  of  the  pons  are  gene- 
rally attended  by  hyperpyrexia,  and  the  urine  is  often  abundant 
and  may  contain  sugar  or  albumen.  These  symptoms  are 
caused  by  irritation  of  the  grey  matter  on  the  floor  of  the 
fourth  ventricle. 

Three  cases  have  recently  been  described  by  Erb,  in  which, 
judging  from  the  symptoms,  the  primary  lesion  was  situated 
in  the  nerve  nuclei  of  the  pons  and  medulla  oblongata.  The 
affection  began  with  pains  in  the  head  and  neck,  and  attained 
its  full  development  in  the  course  of  a  few  months.  The  chief 
symptoms  consisted  of  ptosis,  paresis,  often  associated  with 
atrophy,  of  the  muscles  of  mastication,  tongue,  and  back  of 
the  neck.  There  was  also  weakness  of  the  muscles  supplied 
by  the  superior  branches  of  the  facial  nerve,  associated  with 
phenomena  of  irritation  in  them,  such  as  slight  clonic  spasms ; 
but  the  muscles  supplied  by  the  inferior  branches  were  un- 
affected. In  one  case,  the  movements  of  the  eyeballs  were 
deficient,  but  in  the  other  two  they  were  normal.  Difficulty  of 
deglutition  was  present  in  two  of  these  cases;  buzzing  in  the 
ears,  and  an  abnormal  galvanic  reaction  of  the  left  acoustic 
nerve,  were  observed  also  in  two  cases ;  while  great  weakness 
of  the  extremities  is  mentioned  as  having  been  present  in  two, 
and  slight  weakness  of  the  arms  in  the  remaining  case. 

One  of  these  cases  terminated  fatally,  but  a  post-mortem 
examination  was  not  obtained.  Putting  aside  the  weakness  of 
the  extremities,  which  was  probably  caused  by  implication  of 
the  pyramidal  tracts,  the  other  symptoms  were  evidently  due 
to  disease  of  the  nerve  nuclei  of  the  pons  and  medulla  oblon- 
gata, or  of  the  fibres  of  the  cranial  nerves  in  their  passage 
through  these  structures.  It  is  interesting  to  observe  that  the 
bulbar  nuclei  or  cranial  nerves  implicated  in  these  cases  are 


664  FOCAL  DISEASES,  ACCORDING  TO 

those  that  regulate  the  actions  of  muscles  which  are  frequently 
associated  in  their  actions.  The  association  of  the  actions  of 
these  muscles  is  better  observed  in  animals  than  in  man.  Let 
us  suppose  that  a  dog,  for  instance,  is  lying  in  repose,  with  his 
eyes  closed,  and  that  a  rabbit  or  other  animal  upon  which  he 
preys  rushes  past  to  his  left.  The  noise  made  by  the  passing 
object  is  conducted  to  the  brain  of  the  dog  mainly  through  the 
left  ear,  and  instantly  his  eyelids  open,  the  eyeballs  and  the 
head  are  rotated  to  the  left,  the  mouth  opens  so  as  to  prepare 
for  closure  of  it  upon  the  prey,  and  the  tongue  is  also  ready  for 
protrusion.  It  would  appear  that  some  of  the  muscles  supplied 
by  branches  of  the  cervical  plexus  were  affected  in  these  cases 
as  well  as  those  supplied  by  the  spinal  accessory  nerve.  I  would 
suggest  it  as  probable  that  the  fasciculus  rotundus,  the  func- 
tions of  which  are  not  at  present  known,  is  the  medium  of  asso- 
ciation between  the  mechanism  in  the  upper  end  of  the  pons 
and  crura  cerebri  which  regulates  the  movements  of  the  eye- 
balls, and  the  mechanism  in  the  medulla  oblongata  and  upper 
end  of  the  spinal  cord  which  regulates  the  movements  of  the 
neck  and  head. 

Tumours  of  the  Pons. — A  slow-growing  tumour  may  be 
situated  in  the  centre  of  the  pons,  and  attain  the  size  of  a 
hazel-nut,  without  giving  rise  to  any  symptoms. 

As  in  other  intracranial  tumours,  headache  is  a  frequent 
symptom  of  tumour  in  this  region.  The  headache  is  sometimes 
frontal,  sometimes  occipital,  and  at  other  times  general  and 
deep-seated,  but  it  does  not  afford  any  indication  of  the  situa- 
tion of  the  growth. 

Motor  disturbances  constitute  the  most  characteristic  features 
of  tumours  of  the  pons.  General  convulsions  which  are  not 
unfrequently  caused  by  lesions  like  haemorrhage,  which  occur 
suddenly,  are  very  rare  in  tumours,  and  probably  never 
appear  except  towards  the  last  few  days  of  life  or  when  the 
affection  is  complicated  by  meningitis.  Even  local  spasms  of 
the  muscles  of  the  extremities  are  rare  in  tumour,  inasmuch  as 
the  fibres  of  the  pyramidal  tract  are  slowly  subjected  to  pres- 
sure without  previous  irritation.  Paralysis  is,  therefore,  by  far 
the  most  important  motor  symptom  observed  in  tumour  of  the 
pons.     When  the  tumour  is  situated  in  one  lateral  half  of  the 


THE   LOCALISATION   OF   THE   LESION. 


665 


pons,  especially  in  its  posterior  half,  the  paralysis  assumes  the 
form  of  alternate  hemiplegia.  When,  for  instance,  a  tumour  is 
situated  in  the  right  half  of  the  pons  on  a  level  with  the  nucleus 


at 


so 


RVII 


Fig.  276  (Modified  from  Erb).  Transverse  Section  of  the  Pons  on  a  level  with  the 
Abducens  and  Facial  Boots,  from  a  nine  months  emhryo. — The  right  half  repre- 
sents a  section  made  a  little  lower  than  the  left.  P,  Pyramidal  tract ;  p, 
accessory  portion  of  the  pyramidal  tract ;  Tr  and  Tr',  transverse  fibres  of  the 
pons  ;  so,  superior  olivary  body ;  ale  and  pic,  anterior  and  posterior  nuclei  of  the 
lateral  column  respectively,  representing  the  nucleus  of  the  facial  nerve  ;  EVir, 
root  of  the  facial  nerve  ;  vi',  nucleus  of  the  sixth  nerve  ;  KVI,  root  of  the  sixth 
nerve ;  at,  ascending  root  of  the  trigeminus.  B,  The  internal  division  of  the 
peduncle  of  the  cerebellum  as  it  passes  from  the  cerebellum  ;  L,  posterior  longi- 
tudinal fasciculus;  ar  and  ar',  the  upward  continuation  of  the  internal  and 
external  divisions  of  the  anterior  root-zone  of  the  spinal  cord  ;  t,  fascicuhis  teres. 

of  origin  of  the  sixth  and  seventh  nerves  {Fig.  276),  the  extre- 
mities and  half  the  tongue  on  the  side  opposite  the  lesion  are 
paralysed  from  compression  of  the  pyramidal  tract  before  it  has 
crossed,  while  the  facial  muscles,  including  those  of  the  eyelid 
and  eyebrow  supplied  by  the  seventh,  and  the  external  rectus  are 
paralysed  on  the  side  of  the  lesion.  Under  these  circumstances 
the  facial  paralysis  is  caused  by  compression  of  the  fibres  of 
the  nerve  or  destruction  of  the  facial  nucleus,  and  the  facial 
muscles  often  manifest  the  reaction  of  degeneration.    In  a  case 


666 


FOCAL  DISEASES,  ACCORDING  TO 


of  this  kind  under  my  own  observation  the  reaction  to  both 
currents  was  diminished  in  the  paralysed  muscles,  but  the 
reaction  of  degeneration  never  appeared,  so  that  this  sign  is 
not  always  trustworthy. 

It  is  remarkable  how  seldom  disturbances  of  the  sense  of 
hearing  have  been  observed  in  tumours  of  the  pons,  weakness 
of  hearing  on  the  side  of  the  lesion  being  mentioned  a  few 
times,  but  unilateral  deafness  has,  so  far  as  I  know,  never  been 
described.  Anaesthesia  of  the  opposite  half  of  the  body  and 
extremities  has  been  observed  only  in  about  one-third  of  the 
reported  cases  (Ladame),  and  is  never  so  prominent  a  symptom 
as  the  motor  paralysis.    If  the  tumour  be  situated  in  the  right 


Fia.  277. 


RV. 


Fig.  277  (Modified  from  Erb).  Transverse  Section  of  the  Pons  on  a  level  with  the 
origin  of  the  Trigeminus,  from  a  nine  montlis  human  embryo. — P,  pyramidal 
tract ;  p,  accessory  portion  of  the  pyramidal  tract ;  Tr,  Tr',  transverse  fibres  of 
the  pons ;  at,  ascending  root  of  the  trigeminus  and  gelatinous  substance ;  dt, 
descending  root  of  the  trigeminus ;  r,  root-fibres  of  the  trigeminus  cut  trans- 
versely ;  V,  motor  nucleus  of  the  trigeminus  ;  v',  middle  sensory  trigeminal 
nucleus  ;  EV,  root  of  trigeminus  ;  O,  roots  of  the  fifth  proceeding  from  the  cere- 
bellum ;  L,  Posterior  longitudinal  fasciculus ;  ar  and  a/,  upward  continuation 
of  the  internal  and  external  portions  respectively  of  the  anterior  root-zone  of 
the  spinal  cord. 


THE  LOCALISATION    OF   THE   LESION. 


667 


half  of  the  pons  on  a  level  with  the  fibres  of  origin  of  the  fifth 
nerve  {Fig.  277),  and  if  it  grow  forwards  so  as  to  compress  the 
pyramidal  tract,  the  extremities  and  one-half  the  tongue  are 
paralysed  on  the  opposite  side  of  the  body,  and  the  face 
may  still  be  paralysed  on  the  side  of  the  lesion,  either  from 
compression  of  the  fibres  of  the  pyramidal  tract  belonging  to 
the  facial  nucleus  after  they  have  crossed  in  the  pons,  or  from 


Fig.  278  (Modified  from  Meynert).  Transverse  Section  of  the  Pons  on  a  level  with  the 
upper  end  of  the  Fourth  Ventricle,  from  a  nine  months  human  embryo. — P,  pyra- 
midal tract ;  p,  accessory  portion  of  the  pyramidal  tract ;  Tr,  lY,  transverse 
fibres  of  the  pons  ;  B,  superior  brachium  of  the  pons  ;  L,  posterior  longitudinal 
fasciculus ;  ar  and  ar',  upward  continuation  of  the  internal  and  external  portions 
respectively  of  the  anterior  root-zone  of  the  spinal  cord  ;  v',  middle  sensory 
trigeminal  nucleus  ;  dt,  descending  root  of  the  trigeminus ;  IV,  nucleus  of  the 
fourth  nerve  ;  cc,  aqueduct  of  Sylvius. 

extension  of  the  tumour  downwards  to  reach  the  fibres  of  origin 
of  the  facial  nerve.  The  masticatory  muscles  will  also  be  para- 
lysed on  the  side  of  the  lesion,  and  various  sensory  and  trophic 
disturbances  will  occur  in  the  region  of  distribution  of  the  fifth 
nerve,  such  as  hypersesthesia,  neuralgic  pains,  anaesthesia  often 


668  FOCAL   DISEASES,  ACCORDING  TO 

assuming  the  form  of  ansesthesia  dolorosa,  and  neuroparalytic 
ophthalmia.  The  taste  of  the  corresponding  half  of  the  tongue 
is  often  abolished,  while  smell  is  impaired  in  the  nostril 
of  that  side  owing  to  loss  of  common  sensibility.  Hemi- 
anesthesia of  the  opposite  side  may  exist,  and  then  the  sensory 
disturbance  presents  an  alternate  distribution  like  the  paralysis. 
When  the  tumour  is  situated  in  the  middle  of  the  pons  from 
the  first,  or  extends  from  one  side  to  the  other  during  its 
growth,  all  the  extremities  may  be  paralysed,  either  simulta- 
neously or  successively,  the  muscles  of  the  tongue  on  both  sides 
may  be  weakened,  giving  rise  to  difficulties  of  articulation 
(anarthria)  and  deglutition.  There  may  be  double  facial 
paralysis,  complete  masticatory  paralysis,  paralysis  of  both  the 
external  recti  muscles,  various  sensory  and  trophic  disturbances 
in  the  region  of  distribution  of  the  fifth  nerves,  and  abolition  of 
taste  on  both  sides  of  the  tongue.  The  distribution  of  the 
paralysis  may  present  varieties  other  than  those  just  described. 
Both  sides  of  the  face  may  be  paralysed  and  the  extremities  on 
one  side  only,  or  the  latter  may  be  unaffected ;  on  the  other 
hand,  only  one  side  of  the  face  may  be  affected  and  the  ex- 
tremities on  both  sides.  Similar  variations  may  occur  with 
regard  to  the  distribution  of  the  sensory  disturbances,  although 
they  are  seldom  so  well  marked.  Disorders  of  motor  co- 
ordination may  be  observed  in  lesions  of  the  pons,  especially 
tumours,  similar  to  those  which  will  be  immediately  described 
in  connection  with  disease  of  the  peduncles  of  the  cerebellum. 

Aneurism  of  the  basilar  artery  does  not  appear  to  cause 
symptoms  which  enable  us  to  distinguish  it  from  a  new  forma- 
tion pressing  on  the  poos  in  the  same  situation.  It  is  probable 
that  unilateral  or  bilateral  deafness  is  a  more  frequent  symptom 
of  aneurism  than  of  solid  growths. 

Psychical  disturbances  are  frequently  observed  in  tumours  of 
the  pons,  consisting  of  loss  of  memory,  apathy,  and  stupor,  all 
of  them  symptoms  indicative  of  compression  of  the  brain. 
These  symptoms  are  not,  however,  directly  caused  by  the  affec- 
tion of  the  pons,  but  by  effusion  into  the  ventricles  of  the  brain, 
with  which  the  affection  of  the  pons  is  frequently  complicated. 

When  the  lesion  implicates,  either  directly  or  indirectly,  the 
pneumogastric  nerves  or  their  nuclei  of  origin,  various  disorders 


THE   LOCALISATION   OF   THE   LESION. 


669 


of  respiration  and  circulation  may  be  present,  but  these  usually 
belong  to  the  terminal  phenomena. 

Albuminuria  and  glycosuria  have  been  observed  in  local 
diseases  of  the  pons,  but  by  no  means  with  exceptional 
frequency. 

(ii.)   Lesions  in  the  Peduncles  of  the  Ceeebkum. 
§  761.   The  most  characteristic  features    of   lesions  of  the 
cerebral  peduncle  are  afforded  by  an  alternate  hemiplegia,  in 
which  the  extremities,  half  the  face,  and  half  the  tongue  are 

Fir,  279. 


Fig.  279  (Modified  from  Krauae).  Transverse  Section  of  the  Cms  Cerebri  on  a  level 
with  the  anterior  pair  of  Corpora  Quadrigemina,  from  a  nine  months  embryo. — 
CC,  crusta ;  P,  pyramidal  tract ;  p,  accessory  portion  of  the  pyramidal  tract ; 
ps,  sensory  peduncular  tract ;  LN,  locus  niger ;  RN,  red  nucleus  of  the 
tegmentum  ;  L,  posterior  longitudinal  fasciculus  ;  ar  and  ar',  upward  con- 
tinuation of  the  anterior  root-zone  of  the  spinal  cord ;  III,  third  nerve ; 
III',  nucleus  of  the  third  nerve ;  IT,  fourth  nerve  ;  iv',  nucleus  of  the  fourth 
nerve  ;  iv",  crossing  of  the  fibres  of  the  fourth  nerves  to  opposite  sides  ;  dt, 
descendin;^  root  of  the  trigeminus  ;  cc,  aqueduct  of  Sylvius  ;  x,  crossing  of  the 
fibres  of  the  superior  peduncles  of  the  cerebellum  ;  pf,  fasciculus  of  medullated 
fibres  proceeding  to  the  anterior  pair  of  corpora  quadrigemina. 


670  FOCAL   DISEASES,   ACCORDING   TO 

paralysed  on  the  side  opposite,  and  the  oculo-motor  nerve  on 
the  same  side  as  the  lesion.  If  the  lesion  implicate  the  sensory 
peduncular  fibres  {Fig.  279,  ^s),  hemiansesthesia  may  be  pre- 
sent on  the  side  opposite  the  lesion,  but  the  senses  of  smell 
and  sight  are  not  affected  unless  neighbouring  parts  be  im- 
plicated, or  there  be  secondary  atrophy  of  the  optic  discs  in  the 
case  of  tumour.  A  localised  lesion  in  the  superior  part  of  the 
crus  may  give  rise  to  isolated  paralysis  of  the  fourth  nerve. 
Tumours  of  the  crura  may  paralyse  tbe  oculo-motor  nerves  on 
both  sides.  The  form  of  alternate  paralysis  just  described  is  only 
indicative  of  lesion  of  the  crus  cerebri,  when  the  paralysis  of  the 
limbs  and  of  the  motor  oculi  occur  simultaneously.  It  must 
be  remembered  that  multiple  lesions  in  syphilis,  situated  in  dif- 
ferent parts  of  the  brain,  are  very  liable  to  cause  a  grouping  of 
symptoms  closely  simulating  those  produced  by  a  single  lesion 
in  the  crus  cerebri. 

h.  Lesions  in  the  Peduncles  of  the  Cerehellwm. 

§  762.  One  of  the  most  remarkable  examples  of  haemorrhage 
into  the  middle  peduncle  of  the  cerebellum  is  a  case  described 
by  Nonat: — 

A  woman,  about  .60  years  of  age,  had  an  apoplectic  attack,  charac- 
terised by  unconsciousness,  loss  of  general  sensibility,  and  paralysis. 
The  patient  lay  on  her  right  side,  with  the  head  strongly  rotated  in  the 
same  direction.  The  eyeballs  were  immovable,  the  right  being  rotated 
downwards  and  outwards,  and  the  left  upwards  and  inwards.  The  patient 
died  on  the  day  following  the  onset  of  the  attack.  At  the  autopsy  a  fresh 
hsemorrhagic  focus,  about  the  size  of  a  chestnut,  was  found  situated  in  the 
right  middle  peduncle  of  the  cerebellum,  extending  to  some  extent  into 
the  corresponding  hemisphere.  The  remainder  of  the  brain  and  the 
membranes  were  healthy. 

Tumours  of  the  middle  peduncle  of  the  cerebellum  give 
rise  to  headache  and  dizziness,  trifacial  neuralgia,  neuro- 
paralytic ophthalmia,  and  partial  deafness  on  the  side  of  the 
lesion,  and  disorders  of  motor  co-ordination,  the  tendency  to  fall 
being  in  a  lateral  direction  and  towards  the  side  of  the  lesion. 
If  the  tumour  press  forwards  on  the  pons,  then  all  the  symptoms 
of  a  lesion  in  the  pons  itself  may  be  present.  Any  of  the  bulbar 
nerves  may  then  be  implicated  according  to  the  position  of  the 


k 


THE   LOCALISATION   OF   THE  LESION.  671 

lesion,  while  compression  of  the  pyramidal  tract  and  of  the 
sensory  fibres  may  cause  hemiplegia  and  hemiansesthesia  of  the 
opposite  side.  Conjugate  deviation  of  the  eyes  and  rotation  of 
the  head  may  also  under  these  circumstances  take  place,  the 
deviation  being  directed  away  from  the  side  of  the  lesion. 
According  to  Nothnagel,  lesions  of  the  superior  and  inferior 
peduncles  of  the  cerebellum  do  not  cause  any  characteristic 
symptoms.  He  also  thinks  that  stationary  lesions  of  the  middle 
peduncle  do  not  give  rise  to  symptoms,  and  that  even  irritative 
lesions  only  produce  them  when  the  connection  of  the  peduncle 
with  the  cerebellum  is  not  completely  severed, 

c.  Lesions  in  the  Cerebellum. 

§  763.  Hsemorrhage  into  the  lateral  lobe  of  the  cerebellum 
may  or  may  not  occasion  loss  of  consciousness,  according  to 
its  extent.  The  symptoms  usually  consist  of  intense  cephalalgia, 
generally  situated  in  the  occiput,  but  occasionally  in  the  fore- 
head ;  and  vomiting,  the  latter  being  probably  the  most  constant 
of  all  the  symptoms  of  cerebellar  haemorrhage.  Hemiplegia  is 
not  unfrequently  present,  caused  by  pressure  upon  the  pons,  the 
paralysis  being  sometimes  crossed,  sometimes  direct  (Carion). 

Spasmodic  contractions  of  the  masticatory,  facial,  or  ocular 
muscles  have  occasionally  been  observed,  and  marked  rigidity  of 
the  muscles  of  the  neck  is  a  more  frequent  symptom.  Paralysis 
of  the  face  is  exceptional,  but  when  present  the  orbicular 
muscle  of  the  eyelid  is  implicated,  and  the  paralysis  is  situated 
on  the  side  of  the  lesion.  Strabismus  may  occasionally  be 
present  owing  to  compression  of  one  of  the  motor  nerves  of  the 
eyeball.  Conjugate  deviation  of  the  eyes  has  been  observed,  and 
it  has  always  been  directed  away  from  the  lesion.  The  move- 
ments of  articulation  and  deglutition  are  rarely  affected.  The 
pupils  are  sometimes  dilated,  more  frequently  contracted,  and 
occasionally  insensible  to  light.  In  exceptional  cases  a  certain 
degree  of  angesthesia  of  the  opposite  half  of  the  body  has  been 
observed.  Blindness  has  sometimes  been  observed,  as  might 
have  been  expected  from  the  proximity  of  the  corpora  quadri- 
gemina  to  the  cerebellum. 

A  large  haemorrhage  into  the  middle  lobe  of  the  cerebellum 
may  by  pressing  upon  the  pons  and  medulla  oblongata  cause 


672  FOCAL  DISEASES,   ACCORDING   TO 

sudden  apoplectiform  symptoms,  speedily  terminating  in  death. 
In  hsemorrhages  of  smaller  size  the  symptoms  are  less  marked 
or  wanting.  Hemiplegia  is  not  so  frequently  present  as  in 
lesions  of  the  lateral  lobes,  and  in  about  one-third  of  the 
reported  cases  excitation  of  the  genital  functions  is  mentioned 
Large  stationary  lesions  may  occur  in  the  cerebellum  without 
giving  rise  to  any  recognisable  symptoms  during  life. 

Abscesses  of  the  cerebellum  have  frequently  been  observed  ; 
the  symptoms  on  the  whole  are  like  those  caused  by  tumour. 

Tumours  in  the  cerebellum  give  rise,  in  addition  to  inteose 
paroxysmal  cephalalgia  and  vomiting,  to  characteristic  motor 
disturbances.  The  most  usual  of  these  are  a  staggering  gait, 
reeling,  or  a  tendency  to  fall  to  one  side.  When  the  tumour  is 
situated  in  the  upper  part  of  the  middle  lobe,  the  patient 
frequently  manifests  a  tendency  to  fall  backwards,  while  if  it 
be  situated  in  the  inferior  part  of  the  same,  it  is  probable  that 
the  tendency  is  to  fall  forwards  or  to  revolve  forwards  round  a 
horizontal  axis.  When  the  tumour  is  situated  in  one  of  the 
lateral  lobes,  the  patient  has  a  tendency  to  fall  towards  the  side 
in  which  the  tumour  is  situated.  If  the  tamour  be  growing 
slowly,  the  tendency  to  fall  to  one  side  is  counteracted  to  such 
an  extent  by  cerebral  action  that  the  symptom  is  not  readily 
elicited.  A  slight  stagger  may,  however,  be  observed  to  one 
side  when  the  patient  is  asked  to  turn  round  suddenly,  and 
especially  if  the  eyes  be  closed. 

Symptoms  of  motor  irritation  are  also  observed  in  cases  of 
tumour  of  the  cerebellum.  The  most  usual  of  these  is  a 
tonic  contraction  of  the  muscles  of  the  neck,  causing  retraction 
of  the  head.  This  tonic  contraction  may  extend  to  the  muscles 
of  the  trunk  and  extremities,  giving  rise  to  tetanic  seizures 
(Hughlings- Jackson).  During  these  attacks  the  trunk  is  usually 
arched,  the  head  retracted,  and  the  various  segments  of  the 
lower  extremities  extended  upon  one  another  and  the  trunk, 
so  that  the  body  rests  upon  the  head  and  heels,  as  in  tetanus. 
The  various  segments  of  the  upper  extremities  are  flexed  upon 
one  another,  this  being  the  position  occupied  by  them  in  tetanus. 
The  tonic  contractions  may  be  more  pronounced  on  one  side, 
and  then  the  body  may  be  arched  towards  that  side. 

Movements  of  the  eyeballs  are  frequently  observed  in  cases  of 


THE   LOCALISATION    OF   THE   LESION.  673 

cerebellar  tumour.  These  movements  may  be  vertical,  hori- 
zontal, or  oblique,  and  are  generally  parallel  (Mackenzie). 
Sometimes  they  are  only  observed  during  the  convulsive  attacks, 
but  when  there  is  permanent  rigidity  the  eyes  may  be  rotated 
in  one  direction  and  fixed,  or  present  slight  parallel  oscillatory 
movements. 

Tumours  of  the  cerebellum  are  very  liable  to  be  complicated 
by  effusion  into  the  ventricles  of  the  brain,  due  either  to 
pressure  on  the  vense  magnse  Galeni  or  to  obliteration  of  the 
communication  between  the  spinal  and  cerebral  subarachnoidal 
spaces  (S.  Mackenzie).  This  effusion  in  children  gives  rise  to 
enlargement  of  the  head  and  distension  of  the  fontanelles, 
similar  to  that  occurring  in  chronic  hydrocephalus.  When  the 
fontanelles  have  closed  before  effusion  has  taken  place,  the 
head  is  prevented  from  enlarging,  but  in  these  cases  sudden 
death  is  very  liable  to  occur  from  compression  of  the  floor  of 
the  fourth  ventricle,  and  consequent  arrest  of  the  function  of  the 
respiratory  centre. 

As  already  remarked,  the  most  marked  clinical  characteristic 
of  a  tumour  of  the  superior  part  of  the  middle  lobe  of  the 
cerebellum  is  a  tendency  to  fall  backwards,  or  to  rotate  back- 
wards round  a  horizontal  axis.  In  a  case  under  the  care  of 
Dr.  Leech,  in  which  this  symptom  was  very  marked,  and  in 
which  the  post-mortem  examination  was  conducted  by  myself, 
a  tubercular  tumour,  the  size  of  a  hen's  egg,  was  found  in  the 
right  occipital  fossa,  immediately  under  the  tentorium  and  close 
to  the  falx  cerebelli.  In  the  case  of  a  child,  aged  4  years, 
under  my  own  care,  there  was  a  tendency  to  fall  diagonally 
backwards  and  to  the  right.  I  expected  to  find  a  tubercular 
tumour  in  the  superior  surface  of  the  cerebellum,  situated  be- 
tween the  right  lateral  and  middle  lobes.  Instead  of  that  I 
found  a  tubercular  tumour,  the  size  of  a  pigeon's  egg,  situated 
under  the  tentorium  in  the  occipital  fossa  to  the  left  of  the  falx 
cerebelli,  and  a  second  tumour,  about  the  same  size,  in  the 
right  middle  peduncle.  The  tendency  to  fall  in  a  diagonal 
direction  was  evidently  the  result  of  a  composition  of  forces, 
the  first  tumour  causing  a  tendency  to  fall  backwards  and  the 
second  a  tendency  to  fall  to  the  right. 

The  following  case  is  an  instance  of  tumour  of  the  inferior 


674  FOCAL   DISEASES,  ACCORDING  TO 

part  of  the  middle  lobe  of  the  cerebellum,  although  the  lesion 
was  not  limited  to  that  region : — 

■Tnhn  Thomas  Gould,  set.  14  years,  was  admitted  into  the  Royal  Infirmary 
on  March  5,  1877,  under  the  care  of  Dr.  W.  Roberts,  to  whose  kindness  I 
am  indebted  for  permission  to  publish  the  case.  He  was  a  strong  and 
healthy  boy  until  a  few  months  ago ;  his  parents  were  also  healthy,  and 
there  was  no  family  history  of  consumption  or  any  other  constitutional 
disease.  He  was  a  bricksetter  by  trade,  and  three  months  previously  to 
admission  fell  from  a  ladder  and  struck  the  back  of  his  head  on  the  pave- 
ment, and  since  that  time  he  has  suffered  from  more  or  less  constant 
occipital  headache. 

Condition  on  admission. — As  he  lies  in  bed  he  can  move  his  legs  freely 
in  any  direction ;  but  on  attempting  to  walk,  the  feet  are  alternately  pro- 
jected forwards,  the  heel  coming  down  forcibly  as  in  locomotor  ataxy. 
He  cannot  maintain  the  erect  posture  unsupported ;  and  when  all  external 
aid  is  momentarily  withdrawn,  his  head  shoots  downwards  and  forwards, 
as  if  the  body  were  about  to  revolve  round  a  transverse  horizontal  axis. 
When  the  patient  is  caught  in  the  act  of  falling  and  raised  again  to 
the  erect  posture,  he  complains  of  dizziness,  and  sees  objects  revolving 
from  right  to  left.  On  directing  his  eyes  to  the  right,  a  slight  oscillatory 
movement  of  the  eyeballs  is  observed,  but  there  is  no  nystagmus  when 
he  looks  straight  in  front.  The  patient  is  almost  quite  blind  in  the  left 
eye,  but  can  distinguish  objects  clearly  with  the  right  eye. 

When  the  right  eye  is  fixed  on  an  object,  such  as  a  finger  twelve  inches 
in  front,  a  second  finger  moved  laterally  and  to  the  right  is  seen  until  it  is 
almost  nine  inches  from  the  first,  showing  that  the  field  of  vision  to  the 
right  is  not  sensibly  diminished.  But  starting  again  from  the  finger  on 
which  the  eye  is  fised,  and  moving  the  second  laterally  to  the  left,  the 
latter  disappears  from  view  when  it  is  from  one  to  two  inches  removed 
from  the  former.  I  say  from  one  to  two  inches,  because  his  replies  were  not 
always  the  same,  thus  indicating  that  the  sensitive  and  blind  portions  of 
the  retina  are  not  separated  from  one  another  by  a  sharp  and  defined 
border,  but  fade  insensibly  into  each  other.  The  pupils  are  equal,  both 
being  dilated  and  very  sluggish  to  light.  An  ophthalmoscopic  examination 
reveals  double  optic  nem-itis  with  swollen  disc,  but  there  is  no  atrophy. 
The  other  special  senses  and  the  mental  faculties  are  unaffected,  the  urine 
is  free  from  sugar  or  albumen,  the  appetite  is  good,  and  all  the  other 
functions  of  life  are  normal.  He  was  ordered  iod.  potass.,  grs.  x.,  to  be 
taken  three  times  a-day.  On  March  31,  four  weeks  after  admission,  it  is 
evident  that  the  symptoms  have  altered  considerably.  The  patient  now 
habitually  lies  on  his  back,  or  slightly  inclined  to  one  side.  He  cannot  sit 
erect  without  support,  but  he  has  still  some  degree  of  voluntary  control 
over  his  legs,  although  the  movements  are  feeble.  Cutaneous  sensibility 
is  impaired  in  the  lower  extremities;  he  can  still  feel  when  touched,  but 
he  cannot  locahse  the  touch  well.   Sensibihty  to  variations  of  temperature 


THE  LOCALISATION   OF  THE  LESION.  675 

and  to  pain  is  also  impaired.  There  is  complete  blindness  of  both,  eyes, 
but  there  is  only  slight  atrophy  of  the  optic  discs.  Two  days  ago  he 
passed  his  urine  in  bed  for  the  first  time.  His  bowels  are  very  constipated, 
and  there  is  general  emaciation. 

April  15th. — He  complains  much  of  frontal  headache.  There  is  com- 
plete ansesthesia,  and  entire  loss  of  voluntary  motion  of  the  lower  extremi- 
ties ;  the  stools  and  urine  are  passed  under  him,  and  there  is  a  large  bed- 
sore over  the  sacrum.  He  cannot  hear  the  ticking  of  a  watch  so  well  with 
the  left  as  with  the  right  ear. 

May  14th. — There  is  complete  anaesthesia  of  all  parts  below  a  line 
passing  round  the  body  on  a  level  with  the  anterior  superior  processes  of 
the  ilium.  Keflex  irritabihty  is  entirely  abolished  in  the  lower  extremities, 
as  tested  by  ticlding,  pricking,  and  the  faradic  current.  The  mascles  of 
the  legs  and  thighs  do  not  react  to  either  the  faradic  or  constant  currents. 
The  calf  of  the  right  leg  measures  9j  and  that  of  the  left  only  7^  inches. 
Each  thigh  measures  9|  inches.  The  muscles  of  the  thighs  and  of  the 
right  leg  appear  only  to  be  emaciated  in  proportion  to  the  rest  of  the 
body ;  but  it  is  manifest  that  the  muscles  of  the  left  leg  are  specially 
atrophied.  There  are  deep  bed-sores  over  the  sacrum,  the  prominences  of 
both  thighs,  the  external  maleoh  of  both  ankles,  and  the  inside  of  the  left 
knee.  The  intelligence  is  greatly  blunted,  and  he  hes  in  a  half  stupor,  but 
replies  readily  to  any  simple  question  asked  him.  His  pulse  is  very  feeble 
and  beats  about  140  in  a  minute.  His  appetite  continues  remarkably 
good.  About  a  week  ago  it  was  noticed  that  the  left  eyehd  was  only 
half  closed  when  he  was  asleep,  and  he  could  not  close  it  entirely  by 
a  volimtary  eifort.  There  was  also  shght  paralysis  of  the  left  facial 
muscles,  so  shght  that  the  difference  between  the  two  sides  could  scarcely 
be  detected  when  the  face  was  quiescent,  but  recognisable  when  the  patient 
smiled.  This  affection  of  the  facial  nerve  only  lasted  a  few  days,  and  has 
now  entirely  disappeared.  The  condition  of  his  hearing  cannot  be  satis- 
factorily tested,  owing  to  the  apathetic  state  of  his  intelligence. 

From  this  time  he  lingered  on  without  any  further  special  symptom 
manifesting  itself.  He  became  more  and  more  apathetic  and  extremely 
emaciated,  and  died  on  July  3rd,  four  months  after  entering  the  Infirmary, 
and  seven  months  after  the  fall,  to  which  in  all  probabihty  the  origin  of 
the  disease  may  be  traced. 

Sectio  eadaveris. — Twenty -four  hours  after  death  rigor  mortis  is  mode- 
rately well  established  in  both  extremities.  The  body  is  greatly  emaciated. 
The  calves  of  the  legs  each  measure  7  inches,  and  thighs  7  j  inches.  The 
sacrum,  both  trochanters,  and  the  external  malleolus  of  the  left  foot  are 
exposed  and  denuded  in  consequence  of  extensive  bed-sores.  The  tips  of 
both  ears  are  also  ulcerated,  as  well  as  the  inside  of  the  left  knee. 

On  removing  the  calvarium  the  brain  appeared  to  project,  and  the  con- 
volutions were  flattened.  The  sinuses  and  the  veins  on  the  surface  of  the 
brain  were  gorged  with  blood.  The  substance  of  the  brain  was  somewhat 
soft,  and  the  ventricles  were  distended  with  fluid ;  but  the  cerebrum  was 


676  FOCAL   DISEASES,  ACCOEDING  TO 

healthy  in  other  respects.     Some  grumous  turbid  fluid  escaped  from 
between  the  cerebellum  and  corpora  quadrigemina.     On  inspecting  the 
cerebellum  the  edge  of  a  tumour  was  noticed  between  the  inferior  surface 
of  the  middle  lobe  at  its  posterior  margin  and  the  superior  surface  of  the 
medulla  oblongata ;  while  the  anterior  end  of  the  tumour  could  be  seen 
between  the  cerebellum  and  corpora  quadrigemina.     On  making  a  vertical 
section  of  the  cerebellum  in  the  middle  hne  down  to  the  floor  of  the  fourth 
ventricle,  the  tumour  was  seen  to  occupy  the  whole  of  the  anterior  part  of 
the  middle  lobe  of  the  cerebellum,  being  somewhat  more  developed  on 
the  right  than  on  the  left  side.     In  consistence  the  tumour  was  soft, 
of  a  greyish-red  colour,  the  centre  being  broken  down  so  as  to  form  a 
small  cavity  from  which  the  turbid  fluid  already  mentioned  had  escaped. 
The  tumour  was  not  circumscribed,  its  margins  gradually  blending  with 
the    surrounding   nervous   tissue.     The    growth  passed  along  the  right 
superior  peduncle  of  the  cerebellum  to  reach  the  corpora  quadrigemina, 
and  the  latter  were  somewhat  softened  and  flattened.    On  opening  the 
spinal  canal  the  cord  was  seen  to  occupy  the  whole  of  the  cavity  trans- 
versely, the  diameter  of  the  cord  being  about  one-third  larger  than  that 
in  health.     The  whole  of  the  cord  felt  brawny,  like  bacon.     On  making 
transverse  sections,  from  above  downwards,  half  an  inch  apart,  the  mem- 
branes in  the  cervical  region  were  seen  to  be  adherent,  slightly  thickened, 
and  the  cord  was  softened ;  but  in  the  uj)per  dorsal  region  the  spinal  pia 
mater,  especially  on  the  posterior  aspect,  was  three  times  as  thick  as  in  the 
healthy  cord.     In  the  middle  of  the  dorsal  region  the  thickened  membrane 
had  developed  into  a  dense  well-defined  tiunour,  which  pressed  on  the 
cord  from  behind  forwards,  so  that  only  a  small  part  of  the  anterior  seg- 
ment of  the  cord  was  left.     In  the  lumbar  region,  again,  the  tumour  sur- 
rounded the  cord,  so  that  a  central  core,  about  the  size  of  a  goose  quill,  of 
softened  nervous  tissue  was  all  that  was  left  to  represent  the  spinal  cord. 
The  tumour  was  the  colour  and  texture  of  bacon,  and  much  denser  than 
that  of  the  cerebellum. 

The  left  lung  was  adherent  to  the  chest  walls.  Both  lungs  were 
healthy.  The  heart  was  normal.  The  abdominal  organs  Avere  healthy. 
Microscopic  examination  showed  that  the  tumour  consisted  of  small 
delicate  cells  imbedded  in  a  finely  granular  substance.  The  growth  in  the 
cord  presented  similar  microscopic  characters  to  the  cerebellar  tumour ; 
but  contained  a  larger  amount  of  intercellular  substance. 

The  first  time  I  examined  the  patient  my  diagnosis  was 
"  tumour,  probably  a  glioma,  situated  in  the  inferior  portion  of 
the  middle  lobe  of  the  cerebellum,  and  pressing  forwards  on 
the  corpora  quadrigemina."  The  reasons  for  regarding  the 
case  as  one  of  intracranial  tumour  are  so  manifest  as  scarcely 
to  require  mention.  They  are  the  history  of  an  injury  to  the 
head,  the  gradual  development  and  progressive  character  of  the 


THE   LOCALISATION   OF  THE  LESION.  677 

symptoms,  the  constant  headache,  and  the  existence  of  double 
optic  neuritis.  My  reason  for  believing  that  the  tumour  was 
situated  in  the  inferior  portion  of  the  middle  lobe  of  the  cere- 
bellum was  the  remarkable  manner  in  which  the  head  and 
shoulders  shot  forwards  and  downwards,  as  if  the  patient  were 
about  to  revolve  round  a  horizontal  axis.  The  circumstances  in 
favour  of  the  tumour  being  a  glioma  were  that,  if  the  diagnosis 
with  respect  to  the  localisation  was  correct,  it  probably  grew  in 
the  substance  of  the  nervous  tissue  itself,  and  not  from  the 
membranes;  while  the  appearance  of  the  patient  and  the  family 
history  were  against  tubercle ;  there  was  no  evidence  of  con- 
genital syphilis  ;  and  the  age  of  the  patient  put  cancer  almost 
out  of  the  question. 

My  reasons  for  thinking  that  the  tumour  pressed  forwards 
upon  the  corpora  quadrigemina  were  that  I  thought  this  would 
to  some  extent  explain  the  excessive  staggering  present  during 
attempts  at  walking ;  but  much  more  that  it  would  explain  the 
great  impairment  of  vision  present  at  such  an  early  stage  of  the 
disease.  But  the  peculiar  character  of  the  disorder  of  vision 
demands  an  explanation;  and  for  this  purpose  let  us  take  Char- 
cot's scheme  of  the  decussation  of  the  optic  tracts  as  our  guide. 

In  this  case,  vision  was  almost  totally  lost  in  the  left  eye, 
and  the  state  of  vision  of  the  right  eye  simulated  nasal  hemiopia. 
I  say  simulated,  because  it  was  not  a  case  of  hemiopia  at  all. 
The  condition  of  vision  in  both  eyes  was  that  of  amblyopia  in 
its  progress  towards  amaurosis.  The  amaurotic  condition  was 
nearly  reached  in  both  sides  of  the  retina  in  the  left  eye;  but 
in  the  right  eye  the  right  half  of  the  retina  had  become 
amaurotic,  while  vision  was  tolerably  good  in  the  left  half;  and 
between  the  halves  of  the  right  retina  there  was  a  relatively 
broad  border  land,  where  the  comparatively  good  vision  of  one 
side  faded  gradually  into  the  blindness  of  the  other.  Such  a 
condition  as  this  could  not,  therefore,  have  been  caused  by  the 
pressure  of  a  tumour  on  the  commissure  or  optic  tracts;  it  was 
not  likely  to  have  arisen  directly  from  the  optic  neuritis, 
inasmuch  as  there  was  no  atrophy  of  the  disc ;  and  it  must 
therefore  have  been  caused  by  a  lesion  interfering  with  the 
optic  fibres,  either  directly  or  indirectly  beyond  the  termination 
of  the  optic  tracts  in  the  external  geniculate  bodies. 


678 


FOCAL  DISEASES,  ACCORDING   TO 


It  appeared  to  me  very  probable  that  a  tumour  pressing  on 
the  right  side  of  the  corpora  quadrigemina,  and  extending 
gradually  to  the  left,  would  produce  the  condition  of  vision  met 
with  in  this  case.  The  whirling  of  objects  from  right  to  left 
which  the  patient  described  showed  that  there  was  a  greater 
amount  of  irritation  of  the  right  than  of  the  left  lobe  of  the 
cerebellum,  and  this  rendered  it  probable  that  the  tumour  of 
the  middle  lobe  extended  farther  to  the  right  than  to  the  left. 

Suppose,  then,  that  a  tumour  is  pressing  on  the  corpora 
quadrigemina  from  behind  forwards,  and  from  right  to  left,  the 
fibres  (b  a)  coming  from  the  left  eye,  and  meeting  at  LOD,  would 
be  first  interfered  with,  then  the  fibres  (a!)  coming  from  the 
right  half  of  the  retina  of  the  right  eye  would  be  intercepted 
in  their  passage  behind  the  corpora  geniculata  to  the  opposite 
side.  The  fibres  h'  coming  from  the  left  half  of  the  retina  of 
the  right  eye  would  be  the  last  to  be  injured,  so  that  the  con- 
dition of  vision  which  was  present  in  this  case  would  be  pro- 
duced. It  may  be  urged  that  Charcot's  scheme  of  decussation  is 
merely  diagrammatic,  and  that  the  points  LOG  and  LOD  are 

Fig.  280. 


liV 


Fig.  280  (After  Charcot).  Diagram  of  Decussation  of  the  Optic  Tracts.— T,  Semi- 
decussation in  the  chiasma  ;  TQ,  Decussation  of  fibres  posterior  to  the  external 
geniculate  bodies  (CG) ;  a'  b.  Fibres  which  do  not  decussate  in  the  chiasma; 
b'  a'.  Fibres  coming  from  the  right  eye,  and  coming  together  in  the  left  hemi- 
sphere (LOG) ;  K,  Lesion  of  the  left  optic  tract  producing  right  lateral  hemia- 
nopsia ;  A,  lesion  in  the  left  hemisphere  (LOG),  produces  crossed  amblyopia 
(right  eye).  T,  Lesion  producing  temporal  hemianopsia ;  N  N,  Lesion  producing 
nasal  hemianopsia. 


THE   LOCALISATION   OF   THE   LESION.  679 

supposed  to  represent  positions  in  the  cortex  of  the  hemispheres ; 
but  my  reply  must  be  that  I  am  only  making  a  diagrammatic 
use  of  it.  If  there  is  a  semi-decussation  of  the  optic  nerves  in 
the  chiasma,  and  if  the  fibres  which  do  not  cross  in  that  place 
decussate  behind  the  corpora  geniculata,  then,  whatever  may  be 
the  further  course  of  these  fibres,  some  such  effect  as  that  indi- 
cated would  be  produced  by  a  tumour  pressing  from  behind 
forwards,  and  from  right  to  left  on  the  corpora  quadrigemina. 
This  at  least  was  the  process  of  reasoning  by  which  I  came  to 
the  conclusion  that  the  case  was  one  of  tumour  of  the  anterior 
part  of  the  middle  lobe  of  the  cerebellum,  inclining  to  the 
right  side,  and  pressing  forwards  on  the  corpora  quadrigemina, 
and  this  conclusion  was  verified  to  a  considerable  extent  by  the 
post-mortem.  One  serious  objection  I  always  had  to  this  view 
was,  that  it  was  not  manifest  how  the  floor  of  the  fourth  ven- 
tricle could  escape  under  such  circumstances;  and  yet  there 
was  no  sugar  in  the  urine,  no  polyuria,  and  the  breathing  was 
not  interfered  with.  The  autopsy  explained  this.  It  showed 
that  the  corpora  quadrigemina  were  probably  not  so  much  in- 
terfered with  by  pressure  as  by  extension  of  the  glioma  along 
the  superior  peduncle  of  the  cerebellum  into  the  substance  of 
these  bodies. 

As  the  case  progressed,  it  became  evident  that  there  was 
an  independent  affection  of  the  cord,  as  evinced  by  the  com- 
plete anaesthesia,  and  loss  of  reflex  irritability  in  the  lower 
extremities,  as  well  as  by  the  trophic  changes  already  described. 

Two  suppositions  could  be  made  with  regard  to  the  affection 
of  the  cord.  Either  that  there  was  tumour  pressing  on  the  cord  of 
the  same  nature  as  that  in  the  cerebellum,  or  that  there  was 
extensive  softening  in  the  lumbar  region.  I  must  acknowledge 
that  I  felt  inclined  to  adopt  the  latter  view,  inasmuch  as  I  was 
only  thinking  of  a  circumscribed  growth,  and  was  not  prepared 
to  find  a  new  formation  extending  the  whole  length  of  the  cord. 
It  is  very  probable  that  the  new  growth  had  begun  to  develop 
in  the  spinal  cord  at  the  time  the  patient  was  admitted  into 
the  Infirmary,  and  that  the  symptoms  of  motor  inco-ordination 
observed  were  due,  in  part  at  least,  to  implication  of  the  posterior 
root-zones  in  the  morbid  process. 

In  the  following  case  several  tumours  were  found  in  the  cere- 


680  FOCAL  DISEASES,  ACCORDING   TO 

brum  as  well  as  in  the  cerebellum,  yet  it  was  not  difficult  to 
diagDosticate  the  presence  of  a  tumour  in  the  latter  : — 

Louis  Ikin,  set.  3j  years,  entered  the  Soutliern  Hospital  on  October 
3rd,  1877.  His  mother  stated  that  he  was  always  healthy  until  14  months 
ago,  when  he  had  an  attack  of  chicken-j)Ox,  after  which  he  suffered  from 
sore  eyes.  Soon  afterwards  he  began  to  put  his  hand  to  his  forehead  and 
to  complain  of  pain  there,  and  he  gradually  lost  flesh.  There  was  also 
some  discharge  from  the  right  ear.  These  symptoms  continued  for  about 
eight  months  without  any  appreciable  change;  but  six  months  before 
admission  the  mother  was  awakened  during  the  night  by  a  loud  scream 
from  the  child,  who  was  found  on  the  floor,  having  been  apparently 
projected  from  his  bed  by  the  violence  of  a  convulsion.  On  being  picked 
up  he  was  found  completely  paralysed  on  the  right  half  of  the  body,  and 
aphasic. 

The  paralytic  symptoms  gradually  improved,  but  convulsions  super- 
vened, the  spasms  being  limited  to  the  paretic  side,  and  not  attended  by 
loss  of  consciousness.  He  had  had  the  last  of  those  attacks  a  fortnight 
previous  to  admission.  The  convulsive  movements  always  began  in  the 
right  hand  and  arm ;  but  the  mother  could  not  be  sure  whether  the  light 
side  of  the  face  or  the  leg  was  next  invaded.  The  parents  had  already  lost 
one  of  their  children  from  "  water  on  the  brain ; "  and  another,  who  had 
reached  the  age  of  eight  years,  had  never  been  able  to  speak  more  than 
a  few  words  (congenital  aphasia). 

Present  Condition.  —  There  is  a  slight  degree  of  right-sided  facial 
paralysis,  only  apparent  when  the  child  cries  or  smiles.  There  is  also 
paresis  of  the  right  arm  and  leg ;  but  he  has  considerable  voluntary  power 
over  both.  The  fingers  of  the  right  hand  are  semi-flexed,  and  the  thumb 
bent  inwards  on  the  palm  under  the  fingers.  There  is  some  muscular 
rigidity  on  attempting  passive  movements  of  the  fingers,  hand,  and  fore- 
arm, and  there  is  also  some  degree  of  rigidity  on  attempting  to  move  the 
right  leg  and  foot.  The  child,  on  being  placed  on  his  feet,  can  stand  and 
even  walk  a  few  steps  if  the  upper  part  of  the  body  be  supported,  but  when 
every  support  is  withdrawn  his  face  assumes  a  frightened  expression,  and 
he  would  immediately  fall  on  the  paralysed  side  unless  prevented.  The 
act  of  falling  does  not  consist  of  a  simple  yielding  of  the  paretic  leg,  but 
the  head  and  upper  part  of  the  trunk  shoot  laterally  to  the  right,  while 
the  leg  of  the  same  side  is  maintained  extended. 

His  sight  is  not  good.  He  sees  an  object  held  out  before  him,  but  on 
putting  his  left  hand  out  to  grasp  it  he  has  to  grope  for  it.  There  is 
double  optic  neuritis  with  commencing  atrophy  of  the  discs.  His  speech 
is  almost  lost,  the  only  word  he  can  say  being  "  Mamma." 

November  10th. — About  ten  days  ago  he  had  a  convulsion  which  was 
mainly  limited  to  the  left  side,  this  being  the  first  observed  since  he 
entered  the  hospital.  He  has  had  as  many  as  three  attacks  in  a  day, 
while  some  days  passed  without  his  having  any  attack.    Altogether  he  has 


THE   LOCALISATION   OF   THE   LESION.  681 

had  about  twenty  attacks  in  the  ten  days.  I  was  not  fortunate  enough 
to  see  one  of  these  attacks  myself,  but  I  gave  particular  instructions  to 
the  nurse  to  observe  whether  the  convulsion  began  in  the  hand,  face,  or 
leg.  The  desci'iption  of  the  nurse  was  always  to  the  same  eflfect,  that  the 
attack  began  with  a  scream,  that  the  body  was  bent  like  a  bow,  so  that 
the  left  ankle  and  left  side  of  the  face  nearly  met,  and  that  immediately 
after  the  attack  the  child  resvmied  its  usual  manner,  without  manifesting 
any  tendency  to  sleep.  There  is  no  distinct  jiaralysis  of  the  left  extre- 
mities. 

December  12th. — The  child  has  only  had  a  few  convtdsive  attacks  since 
the  last  report,  and  none  at  aU  during  the  last  fortnight.  He  is  now 
nearly  blind,  being  able  only  to  see  an  object  placed  to  the  left  of  the  left 
eye.  There  is  slight  nystagmus.  The  muscular  rigidity  on  attempting 
passive  movements  of  the  right  arm  and  leg  is  now  more  marked,  and  the 
paralysis  on  that  side  is  also  more  pronoimced.  The  lower  extremities 
are  congested,  of  a  blue  colour,  and  cold,  but  there  is  no  muscular  atrophy. 
The  child  eats  his  food  well,  and  there  is  a  fair  amount  of  subcutaneous 
fat.    He  is  becoming  apathetic  and  passes  his  water  and  stools  under  him. 

January  28th. — He  now  lies  on  his  back,  and  is  getting  more  and  more 
somnolent  and  apathetic.  The  nystagmus  is  more  pronounced  and  there 
is  conjugate  deviation  of  the  eyes  to  the  left.  He  screams  at  night  and 
disturbs  the  other  children  in  the  ward,  on  account  of  which  he  was  dis- 
charged. 

I  continued  to  visit  the  patient  occasionally  at  his  home,  but  the  only 
symptoms  of  note  observed  were  those  of  a  gradual  compression  of  the 
brain,  enlargement  of  the  head,  separation  of  the  fontanelles,  and  fluctua- 
tion over  them.     He  died  on  March  13th,  1878. 

The  post  mortem  was  conducted  24  hours  after  death.  The  ventricles 
were  much  distended  by  a  fluid  efiusion.  Four  tubercular  tumours,  each 
about  the  size  of  a  hazel-nut,  were  found  lying  along  the  sulcus  of  Rolando 
of  the  left  hemisphere,  one  of  them  being  situated  at  its  inferior  extremity 
close  to  the  posterior  extremity  of  the  third  frontal  convolution.  Another 
tumour,  also  about  the  size  of  a  hazel-nut,  was  found  in  the  cortex  of  the 
right  hemisphere  near  the  superior  extremity  of  the  ascending  parietal 
convolution.  A  tumour,  about  the  size  of  a  pigeon's  egg,  was  situated  in 
the  left  lenticular  nucleus,  and  compressing  the  internal  ca]3sule.  The 
inferior  surfaces  of  the  right  and  middle  lobes  of  the  cerebellum  were 
occupied  by  a  tubercular  mass,  which  extended  also  into  the  left  lateral 
lobe.  A  microscopical  examination  of  the  spinal  cord  revealed  sclerosis 
of  the  right  lateral  column. 

The  first  time  I  examined  this  child  the  presence  of  double 
optic  neuritis  rendered  it  clear  that  the  case  was  one  of  intra- 
cranial tumour,  the  slight  stagger  to  the  right  and  the  purulent 
discharge  from  the  right  ear  pointed  to  a  tubercular  tumour  of 


682  FOCAL   DISEASES,  ACCORDING  TO 

the  right  lobe  of  the  cerebellum  ;  while  the  history  of  unilateral 
convulsions  beginning  in  the  right  arm  and  the  aphasia 
pointed  to  the  presence  of  one  or  more  tubercular  tumours 
along  the  sulcus  of  Kolando.  My  diagnosis,  therefore,  was 
tubercular  tumour  situated  in  the  sulcus  of  Rolando  of  the  left 
hemisphere,  and  another  in  the  right  lobe  of  the  cerebellum. 
As  the  case  progressed  the  hemiplegia  became  so  complete  that 
a  cortical  tumour  would  hardly  be  sufficient  to  account  for  it, 
and  I  consequently  assumed  the  existence  of  another  tumour 
in  the  left  lenticular  nucleus,  and  compressing  the  internal 
capsule.  Had  I  adhered  to  this  diagnosis  it  would  have  been 
absolutely  accurate  up  to  a  certain  point.  But  when  the  con- 
vulsions began  in  the  left  half  of  the  body  I  began  to  waver  in 
my  previous  opinion  with  regard  to  the  localisation  of  the 
tumours.  The  unilateral  convulsions  of  the  left  half  of  the  body 
were  either  due  to  irritation  of  the  motor  area  of  the  cortex  of 
the  right  hemisphere,  or  to  irritation  of  the  cerebellum.  From 
the  uniform  description  of  the  nurse  I  came  to  the  conclusion 
that  these  convulsions  were  of  the  nature  of  tetanic  seizures, 
and  therefore  due  to  cerebellar  irritation.  The  unilateral 
character  assumed  by  them  I  explained  by  supposing  that  the 
tumour  was  growing  in  the  left  lobe  of  the  cerebellum  and 
causing  irritation  of  the  left  middle  peduncle,  but  it  is  of  course 
doubtful  whether  there  is  any  justification  for  such  a  supposition. 
I  also  thought  that  the  presence  of  one  tumour,  situated  in  the 
centrum  ovale  of  the  left  hemisphere,  in  such  a  position  as  to 
interrupt  the  fibres  of  the  pyramidal  tract  and  the  fibres  of  the 
corpus  callosum  connecting  the  posterior  extremities  of  the  third 
frontal  convolutions  with  one  another,  might  account  for  the 
right  hemiplegia  and  aphasia,  without  assuming  the  existence 
of  a  tumour  in  the  cortex  and  another  in  the  lenticular  nucleus. 
I  made  a  communication  to  the  Manchester  Medical  Society, 
several  weeks  before  the  death  of  the  patient,  in  which  these 
various  opinions  were  discussed,  and,  owing  to  the  reluctance  I 
felt  in  assuming  the  existence  of  five  or  six  tumours  situated  in 
various  parts  of  the  cerebral  hemispheres  and  cerebellum,  I 
came  to  the  conclusion  that  a  tumour  in  the  centrum  ovale  of 
the  left  cerebral  hemisphere  and  another  in  the  left  lobe  of  the 
cerebellum  might  account  for  the  symptoms.     Had  I  assumed 


THE   LOCALISATION   OF  THE   LESION.  683 

the  existence  of  the  larger  number  of  tumours  my  diagnosis 
would  have  been  almost  absolutely  correct.  I  am  even  now 
unable  to  decide  whether  the  unilateral  spasms  of  the  left  half 
of  the  body  were  of  the  nature  of  tetanic  seizures  or  were  true 
cerebral  convulsions  caused  by  the  irritation  of  the  tumour 
found  in  the  cortex  of  the  right  hemisphere,  near  the  superior 
extremity  of  the  ascending  parietal  convolution. 

In  the  following  case  the  symptoms  pointing  to  an  intracranial 
lesion  were  very  obscure,  yet  the  presence  of  double  optic 
neuritis  and  a  slight  stagger  in  the  gait  of  the  patient  rendered 
it  possible  to  diagnosticate  a  tumour  of  the  right  lobe  of  the 
cerebellum.  For  the  notes  of  the  case  I  am  indebted  to 
Mr.  Luckman  : — 

Annie  E.  M ,  set.  21  years,  domestic  servant,  entered  the  Manchester 

Royal  Infirmary  on  October  21st,  1880,  under  the  care  of  Dr.  Eoss. 
The  patient  was  healthy  until  about  sis  months  ago,  when  she  began  to 
suffer  from  a  dull  headache,  occupying  the  vertex,  and  extending  to  either 
temple.  The  headache  did  not  prevent  her  from  sleeping,  it  was  worse,  as 
a  rule,  on  getting  up  in  the  morning,  and  generally  improved  after  she  had 
had  a  warm  cup  of  tea.  The  headache  was  liable  to  intense  paroxysmal 
aggravation,  and  during  these  attacks  the  patient  generally  vomited. 
About  two  months  ago  she  felt  a  little  unsteadiness  in  walking,  the  head- 
aches increased  in  intensity,  and  she  suffered  so  much  from  retching  and 
vomiting  that  she  was  compelled  to  give  up  her  situation. 

On  presenting  herself  at  the  Infirmary  as  an  out-patient,  a  week  ago, 
the  only  symptoms  complained  of  were  intense  headache,  while  there  were 
great  emotional  disturbances  Hke  those  of  hysteria.  As  the  patient  walked 
across  the  floor  a  shght  staggering  towards  the  right  side  was  obsen^ed, 
this  being  especially  marked  when  she  turned  suddenly  roimd  or  closed 
her  eyes.  It  was  not  then  convenient  to  make  an  ophthalmoscopic 
examination.  When  she  appeared  at  the  end  of  a  week  as  an  out-patient 
the  symptoms  were  still  the  same,  only  the  hysterical  symptoms  were 
detidedly  more  pronoimced,  and  she  was  admitted  as  an  in-patient. 

Present  Condition. — On  admission  an  ophthalmoscopic  examination 
revealed  double  optic  neuritis,  but  she  could  read  the  smallest  print.  She 
never  had  diplopia,  and  there  was  no  strabismus  or  nystagmus.  There 
was  no  paralysis,  no  cutaneous  sensory  disturbances,  and  no  affection  of 
the  special  senses.  The  patient  still  suffered  from  headache,  characterised 
by  remissions  and  paroxysmal  exacerbations,  as  well  as  from  attacks  of 
hiccough.  In  walking  a  slight  stagger  is  occasionally  observed,  the  tendency 
to  fall  being  always  towards  the  right.  She  also  progressed  in  a  slightly 
curved  line,  instead  of  walking  in  a  straight  course.  The  tendency  to 
stagger  is  increased  when  the  patient  closes  her  eyes  or  turns  suddenly 
round. 


684  FOCAL  DISEASES. 

November  2nd. — No  new  symptoms  were  observed  since  last  report 
until  1  o'clock  to-day,  wben  it  was  noticed  that  the  patient's  face  and 
lips  had  become  livid ;  she  also  complained  of  a  dull,  heavy  headache 
seated  on  the  vertex  of  the  head.  At  3  p.m.  respiration  suddenly  ceased, 
and  Dr.  Steele,  who  was  immediately  sent  for,  resorted  to  artificial 
respiration,  and  maintained  the  action  of  the  heart  for  upwards  of  twenty 
minutes,  but  the  pulse  ceased  to  beat  four  minutes  after  the  artificial 
respiration  was  discontinued.  During  this  time  it  was  noticed  that  the 
right  pupil  was  dilated  and  the  right  side  of  the  face  slightly  paralysed. 

The  post-mortem  examination  was  conducted  by  Dr.  A.  H.  Young, 
eighteen  hoius  after  death.  The  cerebral  hemispheres  and  basal  ganglia 
were  normal.  The  ventricles  were  distended  with  fluid,  and  the  aqueduct 
of  Sylvius  was  considerably  dilated.  In  the  cerebellum  a  well-defined 
tiunour  was  found,  forming  a  well-marked  projection  in  the  right  lateral 
lobe.  The  cerebellar  substance  appeared  prominent  in  the  region  of  the 
foramen  magnum,  as  though  pushed  out,  and  seemed  to  press  upon  the 
floor  of  the  fourth  ventricle. 

The  following  case  illustrates  the  movements  of  the  eyeballs 
sometimes  observed  in  tumours  of  the  cerebellum  : — 

In  the  case  of  a  boy,  aged  12  years,  under  my  care  at  the  Southern 
Hosi^ital,  the  symptoms  on  admission  were  headache,  double  optic  neuritis, 
amblyopia,  and  a  slight  stagger  on  walking,  the  tendency  to  fall  not  being 
greater  to  one  side  than  to  the  other.  He  lived  in  the  hospital  nearly  three 
months,  and  during  that  time  the  optic  neuritis  gave  place  to  atrophy  of 
the  discs,  and  the  amblyopia  to  amaurosis ;  while  the  change  in  the  other 
symptoms  consisted  of  a  progressive  impairment  of  the  mental  faculties 
from  gradual  compression  of  the  brain,  the  patient  ultimately  dying  coma- 
tose. During  the  last  three  days  of  life  there  was  rigidity  of  the  muscles 
of  the  back  of  the  neck  along  with  vertical  and  parallel  movements  of  the 
eyeballs,  consisting  of  an  upward  alternating  with  a  downward  rotation. 
The  time  occupied  by  each  rotatory  movement  was  remarkably  uniform, 
and  as  many  as  twenty  of  these  occurred  in  a  minute.  At  the  autopsy 
two  tubercular  tumours,  each  about  the  size  of  a  pigeon's  egg,  were  found 
symmetrically  situated  in  the  inferior  surfaces  of  the  lateral  lobes.  A 
third  tumour,  about  the  size  of  a  hazel-nut,  was  found  in  the  superior 
portion  of  the  middle  lobe. 


685 


CHAPTER    X. 


11.    DIFFUSED   DISEASES   OF   THE  ENCEPHALON. 


(I.)    ANEMIA   AND    HYPEREMIA    OF    THE    BRAIN. 

(i.)   Anemia  of  the  Brain. 

§  764.  History. — Dr.  Marshall  Hall  was  one  of  the  first  to  direct 
attention  to  the  symptoms  produced  by  cerebral  antemia,  and  as  these 
symptoms  in  children  closely  simulate  those  of  acute  hydrocephalus  he 
proposed  to  call  the  condition  hydrocephaloid  or  hydrencephaloid  disease. 
He  also  pointed  out  that  symptoms  which  had  hitherto  been  attributed 
to  cerebral  hypersemia  were  really  due  to  ansemia,  and  were  such  as 
frequently  occurred  after  exhausting  hsemorrhages.  About  the  same  time 
Abercrombie  gave  a  similar  interpretation  to  the  symptoms  of  syncope  and 
of  apoplexia  ex  inanitione.  The  study  of  the  effects  of  ligature  of  the 
carotids  by  Sir  Astley  Cooper  led  the  way  in  the  experimental  investigation 
of  cerebral  anaemia,  which  was  completed  in  more  recent  years  by  the 
labours  of  Schifi",  Kussmaul  and  Tenner,  and  many  others. 

§  765,  Experimental  Investigation. — When  one  of  the  common  carotid 
arteries  is  compressed,  there  is  first  indistinctness  of  vision,  and  after  a  few 
seconds  a  prickling  sensation  is  felt  in  half  the  face,  followed  by  a  similar 
sensation  in  the  limbs  and  opposite  half  of  the  body.  General  sensibility 
becomes  indistinct,  the  sense  of  touch  is  impaired,  and  even  trembling  and 
convulsive  twitchings  may  occur ;  but  after  three  or  four  minutes  these 
symptoms  disappear,  because  the  collateral  circulation  soon  compensates 
the  effects  of  the  compression.  Compression  of  both  carotids  is  followed 
by  indistinctness  of  vision  amounting  to  almost  complete  blindness,  con- 
traction followed  by  dilatation  of  the  pupils,  the  respiration  becomes  slow, 
deep,  and  sighing,  and  there  is  a  sense  of  oppression  about  the  thorax. 
These  symptoms  are  followed  by  drowsiness,  staggering,  and  loss  of  con- 
sciousness ;  and  if  the  compression  be  continued,  universal  muscular 
twitching,  symptoms  of  choking,  and  vomiting  appear  (Schiff). 

If  the  circulation  through  both  carotid  and  vertebral  arteries  be  sud- 
denly interruptef^,the  pupils  first  contract,  but  soon  dilate  again,  the  eye- 


686  DIFFUSED   DISEASES  OF   THE   ENCEPHALON. 

balls  roll  upwards  and  outwards,  the  jaws  are  clenched,  and  the  respiration, 
at  jBrst  short,  becomes  slow  and  deep  ;  these  symptoms  are  soon  followed 
by  general  muscular  relaxation,  loss  of  consciousness,  and  general  convul- 
sions. Similar  symptoms  attend  bleeding  to  death.  If  the  animal  be 
previously  enfeebled  by  loss  of  blood,  death  results  from  syncope  without 
convulsions.  The  animal  may  be  kept  for  a  short  time  in  a  condition 
simulating  death ;  but  if  artificial  respiration  be  maintained,  gradual 
recovery  takes  place  when  the  blood  is  allowed  to  flow  again  through 
the  vertebral  arteries. 

It  has  been  found  that  obstruction  of  the  circulation  through  the 
carotids  in  animals  only  causes  trifling  effects  in  comparison  with  the 
symptoms  produced  in  man,  showing  that  the  anterior  lobes  are  of  much 
greater  importance  in  man  than  in  animals. 

§  766.  Etiology. — Anaemia  of  the  brain  is  caused  by  in- 
fluences which  act  upon  the  vascular  system  of  the  brain  alone, 
or  it  may  form  only  a  part  of  general  anasmia.  The  entire  brain 
may  be  affected,  causing  universal  ancemia,  or  it  may  be 
limited  to  certain  parts  causing  partial  ancemia.  The  symp- 
toms also  differ  much  according  as  the  anaemia  is  suddenly  or 
gradually  produced. 

Acute  -tjuniversal  cerebral  ancemia  is  caused  in  its  most 
typical  form  by  a  sudden  loss  of  a  large  quantity  of  blood. 
The  most  frequent  causes  of  this  form  of  cerebral  anaemia  are 
post  partum  haemorrhage,  haemorrhages  from  the  nose,  lungs, 
stomach,  and  intestines,  and  large  losses  of  blood  from  external 
injuries.  A  sudden  fall  of  arterial  tension  from  the  relaxation  of 
large  vase  alar  areas  in  other  parts  of  the  body  may  also  cause 
cerebral  anaemia.  The  faintness  which  frequently  accompanies 
the  rapid  withdrawal  of  ascitic  fluid,  or  immediately  after 
parturition,  is  probably  caused  by  the  flow  of  a  large  quantity 
of  blood  into  the  relaxed  abdominal  vessels. 

Cerebral  anaemia  is  a  frequent  accompaniment  of  organic 
diseases  of  the  heart,  more  especially  of  aortic  regurgitation? 
in  which  death  often  results  from  syncope.  Weakness  of  the 
muscular  walls  of  the  heart,  whether  temporary  "as  after  acute 
febrile  diseases,  or  permanent  as  in  fatty  degeneration,  is  apt 
to  produce  faintness  from  cerebral  anaemia.  Irritation  of  the 
vagus  may  cause  cerebral  anaemia  by  a  temporary  arrest  of  the 
heart's  action.    Fainting,  the  result  of  mental  impressions,  may 


DIFFUSED   DISEASES   OF  THE   ENCEPHALON.  687 

be  produced  in  this  way,  although  spasm  of  the  cerebral  vessels 
from  irritation  of  the  sympathetic  nerves  may  be  the  cause. 

Intense  pain  may  cause  faintness  or  even  syncope,  which 
may  result  from  reflex  irritation  of  the  vagus,  or  direct  irri- 
tation of  the  sympathetic.  But  the  direct  effect  produced 
on  the  nerve-centres  must  also  contribute  to  the  result.  The 
strong  nervous  discharges  caused  by  the  external  injury  ascend 
along  centripetal  fibres  and  produce  a  corresponding  strong 
nervous  discharge  from  the  higher  nerve-centres,  which  is 
conducted  along  centrifugal  fibres  to  the  periphery,  giving  rise 
to  the  cries  and  various  bodily  contortions  which  indicate  pain. 
Again,  strong  nervous  discharges  from  the  higher  centres  must 
be  followed  by  exhaustion  and  consequent  impairment  or  aboli- 
tion of  function,  just  as  the  discharges  of  epilepsy  are  accom- 
panied by  unconsciousness. 

Acute  universal  cerebral  ansemia  may  probably  be  caused  by 
various  poisons,  although  anaesthetic  agents,  like  chloroform  and 
ether,  probably  act  less  upon  the  circulation  of  the  brain  than 
upon  the  cerebral  tissues  themselves. 

Chronic  Universal  Cerebral  Ancemia. — This  variety  is 
caused  by  any  condition  which  withdraws  a  large  quantity  of 
the  nutrient  fluids  from  the  body,  such  as  repeated  losses  of  blood, 
severe  diarrhoea,  chronic  suppuration,  and  all  causes  of  general 
anaemia.  Chronic  anaemia  of  the  brain  also  occurs  in  certain 
valvular  lesions  and  fatty  degeneration  of  the  heart.  The  intro- 
duction of  foreign  matter  into  the  cavity  of  the  skull,  as  inflam- 
matory exudations  in  meningitis,  the  fluid  which  transudes  in 
oedema,  haemorrhagic  foci,  and  cerebral  tumours,  may  also  cause 
chronic  anaemia  of  the  brain. 

Partial  Cerebral  Ancemia. — Partial  anaemia  is  caused  when 
one  of  the  vessels  of  the  brain  is  obstructed,  or  when  external 
pressure  is  exerted  by  a  tumour  on  a  vascular  area,  but  these  cases 
have  already  been  described.  Unilateral  anaemia  is  seen  after 
ligature  of  the  carotid  on  one  side ;  but  the  symptoms  are  only 
temporary,  except  in  the  cases  in  which  there  is  an  impervious 
condition  either  congenital  or  acquired  of  the  communicating 
arteries  of  the  circle  of  Willis. 


688  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

§  767.  Syimptoms. 

Acute  Universal  Cerebral  Ancemia. — The  initial  symptoms 
are  obscuration  of  the  senses,  buzzing  in  the  ears,  dizziness,  con- 
traction followed  by  dilatation  of  the  pupils,  imperfect  reaction 
to  external  stimuli,  and  loss  of  consciousness.  The  surface 
becomes  cold  and  pale,  the  respiratory  movements,  accelerated  at 
•first,  become  slow,  and  this  condition  is  frequently  followed  by 
general  convulsions  and  coma.  The  symptoms  which  are  pro- 
duced by  the  temporary  anaemia  caused  by  powerful  mental 
impressions  differ  considerably  from  those  just  described.  At 
first  there  is  some  degree  of  mental  incoherence  manifested  by 
the  inability  of  the  patient  to  direct  his  attention  to  a  particular 
object,  a  feeling  of  oppression  in  the  chest,  along  with  a  ten- 
dency to  gape.  The  face  becomes  pale,  a  cold  perspiration 
breaks  out  on  the  forehead  and  sometimes  on  the  entire  body, 
and  there  is  general  muscular  relaxation.  There  is  ringing  in 
the  ears,  dimness  of  sight,  nausea,  and  sometimes  vomiting. 
The  pulse  is  small,  compressible,  but  regular.  The  patient  may 
now  begin  to  recover  or  fall  insensible  to  the  ground,  and  after 
a  few  moments  in  the  recumbent  position  he  begins  to  recover. 
This  constitutes  an  ordinsiry  fainting-fit  or  syncope. 

Chronic  Universal  Cerebral  Ancemia. — In  these  cases  well- 
marked  mental  irritability  is  observed,  associated  with  fretful- 
ness,  restlessness,  uneasy  sleep  disturbed  by  dreams,  and  a 
certain  amount  of  intolerance  of  light  and  sound.  These 
symptoms  are  frequently  succeeded  by  the  phenomena  of 
depression,  and  sometimes  the  latter  predominate  from  the 
first.  The  patient  suffers  from  almost  constant  headache, 
vertigo,  nausea,  and  faintness.  The  pulse  is  small  and  com- 
pressible, the  cardiac  impulse  feeble,  and  there  is  great  disincli- 
nation for  either  mental  or  physical  exertion. 

In  the  severe  forms  of  chronic  or  sub-acute  cerebral  anaemia, 
such  as  that  produced  by  starvation,  or  that  which  arises  during 
the  course  of  exhausting  fevers,  delirium  becomes  a  promi- 
nent symptom.  Occasionally  delirium  comes  on  after  haemor- 
rhage ;  but  it  is  generally  a  late  symptom,  and  occurs  more 
frequently  with  robust  than  feeble  people.  This  symptom 
is  more  common  when  the  anaemia  is  due  to  starvation,  and 
under  these  circumstances  it  is  called  the  "  delirium  of  inani- 


DIFFUSED  DISEASES   OF   THE   ENCEPHALON.  689 

tion."  The  delirium  which  comes  on  after  the  crisis  or  during 
convalescence  in  febrile  diseases  is  also  to  be  attributed  in 
great  part  to  defective  nutrition  of  the  brain.  During  the 
delirium  of  cerebral  anaemia  the  patients  are  excited  and  some- 
times maniacal ;  there  are  illusions  of  sight  and  hearing,  and 
delusions  of  persecution.  The  duration  of  this  condition  is 
variable ;  it  may  last  a  few  hours  or  days  only,  but  it  sometimes 
continues  for  weeks  and  occasionally  passes  into  permanent 
insanity. 

Cerebral  anaemia  is  seen  in  infants  after  severe  diarrhoea,  or 
other  exhausting  disease ;  and  as  this  is  the  form  which  was 
called  by  Marshall  Hall  hydrocephaloid  or  hydrenc&phaloid 
disease,  it  demands  special  notice.  The  affection  may  be  divided 
into  two  stages — the  first,  that  of  irritability ;  the  second,  that 
of  torpor,  resembling  the  first  and  second  stages  of  hydrocephalus 
respectively.  In  the  first  stage,  the  infant  is  irritable,  restless, 
with  flushed  face,  warm  skin,  and  frequent  pulse ;  the  patient 
starts  on  being  touched  or  on  Bearing  any  sudden  noise,  sleep 
is  disturbed  and  interrupted  by  sighs,  moans,  or  screams. 
During  the  second  stage  the  countenance  becomes  pale,  the 
cheeks  and  extremities  cold,  the  eyelids  are  half  closed,  the 
eyes  sunk  in  their  sockets,  there  is  frequently  slight  strabismus, 
and  the  pupils  are  dilated  and  do  not  contract  to  light.  The 
breathing  is  irregular  and  sighing,  the  voice  husky,  and  there 
is  sometimes  a  teasing  cough  with  rattling  in  the  throat.  A 
most  important  symptom  which  distinguishes  this  disease  from 
hydrocephalus  is  that  the  fontanelle,  instead  of  being  tense  as 
in  the  latter  disease,  is  depressed.  The  child  inclines  almost 
constantly  to  fall  into  a  sleep,  which  may  pass  into  coma  and 
death,  but  under  appropriate  treatment  gradual  recovery 
usually  takes  place. 

§  768.  Morbid  Anatomy. — The  blood-vessels  of  the  mem- 
branes of  the  brain  are  usually  more  or  less  empty,  but  there 
is  almost  always  a  certain  quantity  in  the  larger  veins  and 
sinuses.  A  very  characteristic  appearance  is  presented  by  the 
pia  mater  in  cases  of  chronic  anaemia  associated  with  condi- 
tions which  induce  general  oedema.  The  pia  mater,  especially 
over  the  superior  surface  of  the  hemispheres,  is  of  a  pale  colour, 
s  s 


690  DIFFUSED  DISEASES   OF   THE   ENCEPHALON. 

somewhat  opaque,  and  so  oedematous  that  it  pits  on  pressure. 
This  condition  is  especially  marked  in  chronic  Bright's  disease, 
and  I  have  frequently  been  able  to  predict  on  opening  the  skull 
at  a  post-mortem  that  we  should  find  contracted  kidneys.  ,  In 
these  cases  the  cavities  of  the  arachnoid  and  the  lateral  ven- 
tricles contain  together  about  two  ounces  of  serous  fluid,  and 
the  choroid  plexuses  are  oedematous.  At  the  junction  of  the 
posterior  and  descending  horns  of  the  ventricle  the  oedema  of  the 
choroid  plexuses  is  so  great  that  it  gives  the  appearance  of  two 
or  three  cysts,  each  about  the  size  of  a  pea,  growing  from  them. 
The  grey  substance  is  pale,  and  somewhat  decolourised.  The 
white  substance  is  paler  than  usual,  and  there  is  an  absence 
of  blood-points. 

§  769.  Morbid  Physiology. — Cerebral  anaemia  is  a  complex 
condition,  depending  not  merely  upon  a  deficiency  of  the 
quantity  of  blood  supplied  to  the  brain,  but  also  upon  a  change  in 
its  quality,  and  upon  a  diminution  in  the  intracranial  pressure. 
It  is  exceedingly  difficult  to  apportion  to  each  of  these  their 
due  share  in  the  production  of  the  symptoms.  A  glance,  how- 
ever, at  the  empirical  laws  of  nerve  irritability  will  afford  the 
key  to  the  interpretation  of  the  more  prominent  symptoms  of 
the  disease.  When  a  nerve  is  imperfectly  nourished  its  irrita- 
bility is  first  increased ;  or,  in  other  words,  a  slight  degree  of  its 
usual  stimulus  will  cause  it  to  discharge  its  energy.  When  the 
deficiency  of  nutrition  is  continued  the  increase  of  the  irrita- 
bility, which  is  only  a  temporary  condition,  is  followed  by  a  de- 
crease, and  complete  withdrawal  of  nourishment  again  is  followed 
by  exhaustion.  This  principle  will  help  to  explain  the  leading 
phenomena  produced  by  cerebral  anaemia.  When  a  healthy 
individual  suddenly  loses  a  large  quantity  of  blood,  the  irrita- 
bility of  the  nervous  matter  becomes  increased,  and  phenomena 
of  irritation,  such  as  contraction  of  the  pupils,  restlessness,  and 
ringing  noises  in  the  ears,  are  produced,  and  there  may  soon  be 
a  large  discharge  of  nervous  energy  from  the  cortex  of  the 
brain,  giving  rise  to  general  convulsions  followed  by  uncon- 
sciousness. 

When  the  anaemia  takes  place  more  gradually,  the  outgoing 
discharges  will  be  less  powerful,  and  they  will  only  produce  the 


DIFFUSED   DISEASES   OF   THE   ENCEPHA.LON.  691 

signs  of  mental  irritability,  to  be  followed  by  a  drowsy  or  som- 
nolent condition  instead  of  complete  loss  of  consciousness.  If, 
on  the  other  hand,  the  nervous  energy  of  the  cortex  of  the 
cerebrum  be  already  exhausted  by  overwork  prior  to  the  loss  of 
blood,  the  phenomena  of  depression  may  exhibit  themselves 
from  the  beginning  without  being  preceded  by  any  signs  of 
irritation,  and  under  these  circumstances  unconsciousness  may 
be  produced  without  being  preceded  by  general  convulsions. 

§  770.  Course  and  Duration. — Simple  faintness  from  emo- 
tional causes  usually  soon  ends  in  recovery,  although  a  fatal 
case  is  rarely  met  with ;  but  it  is  probable  that  in  these  cases 
there  is  some  amount  of  degeneration  of  the  muscular  walls  of 
the  heart.  The  syncope  which  attacks  patients  convalescent 
from  acute  disease,  when  they  assume  the  erect  posture  for  the 
first  time,  is  more  dangerous  and  liable  to  prove  fatal. 

§  771.  Diagnosis. — The  symptoms  of  cerebral  angemia  are 
not  unlike  those  of  hypersemia  of  the  brain,  and  the  delirium 
from  anaemia  which  arises  in  the  course  of  acute  diseases  may 
very  readily  be  mistaken  for  the  delirium  of  active  congestion. 
Anaemia  and  hyperasmia  of  the  brain  can,  indeed,  only  be  dis- 
tinguished from  one  another  by  careful  attention  to  the  con- 
comitant symptoms.  The  cerebral  symptoms  themselves  are 
not  to  be  relied  upon,  as  the  delirium  in  ansemia  may  be  as 
violent  as  in  congestion,  and  the  colour  of  the  face  is  not  always 
a  faithful  index  of  the  condition  of  the  cerebral  circulation. 
The  diagnosis  must  be  founded  upon  the  general  history  of  the 
case,  the  nature  of  the  concomitant  symptoms,  and  the  treat- 
ment which  has  been  adopted  prior  to  the  onset  of  the  delirium. 
As  further  aids  to  the  diagnosis,  it  may  be  tried  whether  the 
erect  or  horizontal  posture  has  any  influence  in  aggravating  or 
diminishing  the  symptoms,  and  whether  they  are  increased  or 
relieved  by  alcoholic  stimulants.  The  state  of  the  general 
circulation  must  also  be  carefully  examined. 

§  772.  The  prognosis  in  a  case  of  hydrocephaloid  disease 
is  generally  favourable,  provided  that  the  true  nature  of  the 
affection   be   recognised   and  appropriate  treatment   adopted. 


692  DIFFUSED   DISEASES   OF   THE   ENCEPHz'iLON. 

A  similar  remark  may  be  made  with  respect  to  the  delirium 
of  anaemia,  although  it  may  sometimes  be  prolonged  and 
occasionally  prove  incurable.  The  prognosis  of  the  cerebral 
anaemia  caused  by  heart  disease  will  depend  upon  the  gravity 
of  the  cardiac  affection ;  and  fatal  syncope  is  very  apt  to  occur 
in  aortic  regurgitation  when  accompaned  by  dilatation  of  the 
left  ventricle. 

§  773.  Treatment — The  treatment  must  vary  according  as 
the  anaemia  is  acute  or  chronic,  limited  to  the  brain,  or  affecting 
the  entire  body. 

In  an  ordma,ry  fainting  Jit  the  patient  should  as  speedily  as 
possible  be  placed   in   the  recumbent  posture,  and   recovery 
usually  takes  place    without  any  further  treatment.     If  the 
symptoms  are  more  persistent,  some  form  of  cutaneous  irri- 
tation may  be  employed.    The  most  usual  and  readiest  method 
is  to  sprinkle  the  face  with  cold  water,  or  to  fleck  the  face  with 
the  corner  of  a  towel  dipped  in  cold  water.     A  more  efficient 
method,  however,  is  the  application  of  the  metallic  electric 
brush  if  a  battery  happen  to  be  at  hand.      Mustard  appli- 
cations have  been  employed,  but  they  are  too  slow  in  their 
action.     The  preparations  of  ammonia  and  other  substances, 
which  irritate  the  trigeminus  and  olfactory  nerves,   are  also 
useful  adjuncts  to   the   treatment,   and  stimulating   enemata 
may  be  resorted  to.     As  soon  as  the  patient  can  swallow,  and 
especially  if  the  heart's  action  be  feeble,  stimulants,  such  as 
coffee  or  brandy,  must  be  administered.    The  more  volatile  the 
agent  the  sooner  will  it  be  absorbed,  hence  ether  is  especially 
useful;  and  the  same  may  be  said  of  champagne,  since  the 
experiments  of  Bernard  have  proved  that  the  presence  of  the 
carbonic  acid  promotes  the  absorption  of  alcohol. 

In  severe  cases  of  cerebral  anaemia  after  profuse  haemorrhage, 
in  addition  to  the  means  already  mentioned,  the  body  of  the 
patient  ought  to  be  covered  with  warm  blankets  or  other 
clothing  and  surrounded  by  bottles  containing  hot  water ;  and 
in  order  to  increase  the  flow  of  blood  towards  the  brain  the 
head  ought  to  be  kept  in  a  low  position,  while  pressure  is 
maintained  over  the  abdominal  and  axillary  arteries,  a  pro- 
ceeding which  will  direct  the   stream   of  blood   towards   the 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  693 

carotids  and  will  consequently  raise  the  tension  in  these  vessels. 
In  cases  of  severe  and  prolonged  cerebral  ansemia  from  loss  of 
blood  transfusion  should  be  tried  as  a  last  resort. 

The  cerebral  anaemia  which  arises  during  the  course  of  acute 
diseases  must  be  treated  by  the  judicious  use  of  wine  and 
nourishing  diet,  and  if  the  case  admit  of  it  by  such  tonics  as 
quinine  and  iron.  The  patient  should  also  be  instructed  not  to 
raise  his  head  from  the  pillow  so  long  as  the  action  is  accom- 
panied by  dizziness  or  other  symptoms  indicative  of  anaemia. 
When  delirium  or  other  forms  of  cerebral  excitement  accom- 
panies the  ansemia,  the  great  aim  of  treatment  should  be  to 
procure  sleep.  A  full  dose  of  chloral  sometimes  acts  very  well 
in  these  cases;  but  according  to  my  experience  an  opiate  is 
much  more  reliable  and  efficacious.  A  single  subcutaneous 
injection  of  morphia  is  frequently  followed  by  calm  sleep,  and 
the  patient  awakes  with  restored  mental  faculties.  The  dose 
should  not,  as  a  rule,  be  more  than  from  one-eighth  to  one- 
fourth  of  a  grain. 

Hydrocephaloid  disease  must  be  treated  on  the  same  general 
principles.  The  diarrhoea  or  other  disease  which  has  produced 
the  ansemia  must  be  attended  to ;  and  the  case  must  be  treated 
by  warm  applications,  appropriate  nourishment,  and  stimulants, 
such  as  wine  and  musk. 

(ii.)     HTPEEiEMIA  OP  THE  BeAIN, 

§  774.  Etiology. — Congestion  of  the  brain,  like  congestion 
of  other  organs,  may  be  either  active  or  passive.  The  former  is 
also  called  the  hypercemia  of  fluxion,  and  the  latter  the 
hypercemia  of  stasis. 

Active  Congestion. — Irritation  of  the  tissues  of  the  brain 
causes  congestion,  but  such  cases  generally  terminate  in  en- 
cephalitis, and  the  congestion  is  usually  more  or  less  local.  The 
causes  of  universal  active  congestion  must,  therefore,  be  sought 
in  the  state  of  the  general  circulation  rather  than  in  the  brain 
itself.  All  conditions  which  raise  the  arterial  tension  must  tend 
to  produce  congestion  of  the  brain,  unless,  indeed,  the  increased 
tension  be  caused,  as  in  chronic  Bright's  disease,  by  a  diminu- 
tion of  the  lumen  of  the  arterioles  all  over  the  body,  including 
those  of  the  brain.     An  increased  flow  of  blood  to  the  brain 


694  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

may  be  produced  artificially  by  surrounding  one  or  more  of  the 
limbs  by  Esmarck's  bandages,  or  by  compression  of  the  ab- 
dominal aorta,  or  of  some  of  the  large  arteries  of  the  body. 

Exposure  of  the  surface  of  the  body  to  cold  raises  the  arterial 
tension  and  occasions  congestion  of  the  internal  organs,  and  the 
same  effect  is  produced  during  the  cold  stage  of  intermittent 
fever,  and  the  rigors  which  usher  in  most  severe  acute  diseases. 
The  sudden  arrest  of  habitual  discharges  may  produce  con- 
gestion of  the  brain  by  increasing  arterial  tension. 

Hypertrophy  of  the  heart  does  not  often  cause  congestion  of 
the  brain,  inasmuch  as  the  hypertrophy  is  always  compensatory 
to  some  resistance  offered  to  the  onward  flow  of  blood.  Con- 
gestion of  the  brain  may,  however,  be  caused  by  the  increased 
activity  of  the  heart,  which  accompanies  emotional  excitement. 
But  in  such  cases  the  direct  excitement  of  the  tissues  of  the 
brain,  which  underlies  the  emotional  disorder,  must  co-operate 
with  the  increased  activity  of  the  heart  as  an  important  factor 
in  the  production  of  congestion. 

Paralysis  of  the  sympathetic  or  irritation  of  the  inhibitory 
nerves  of  the  arteries  of  the  brain  may  produce  cerebral 
hypergemia. 

Plethoric  and  nervous  individuals,  especially  of  the  female 
sex,  are  sometimes  attacked  with  dizziness,  headache,  and 
flushing  of  the  face  in  the  absence  of  emotional  excitement  or 
disturbance  of  the  circulation  generally  that  would  account  for 
the  symptoms,  which  must,  therefore,  be  referred  to  derange- 
ment of  the  vaso-motor  nerves  of  the  brain.  The  vertigo  and 
drowsiness  which  accompany  irritation  of  the  stom^'ch  is  pro- 
bably often  caused  by  cerebral  hypersemia.  The  experiments 
of  S.  Mayer  and  Pribram  have  shown  that  direct  electrical  or 
mechanical  irritation  of  the  walls  of  the  stomach  produces  an 
increase  of  the  arterial  tension  and  slowing  of  the  pulse,  caused 
probably  by  a  reflex  contraction  of  the  arterioles  of  the  body 
generally.  If,  under  these  circumstances,  the  contraction  of 
the  arterioles  of  each  organ  in  the  body  were  in  a  condition  of 
perfect  equilibrium  with  that  of  the  arterioles  of  every  other 
organ,  no  congestion  of  any  of  them  would  take  place.  It  is 
not  likely  that  complete  equilibrium  can  exist  between  the 
contraction  of  the  vessels  of  all  the  organs  of  the  body  in  any 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON,  695 

case,  and  it  is  manifest  that  the  organ  whose  vessels  began 
first  to  dilate  must  become  more  or  less  congested. 

Some  poisonous  agents  appear  to  have  the  effect  of  producing 
congestion  of  the  brain  ;  most  of  the  narcotics  and  stimulants 
appear  to  me  to  act  upon  the  tissues  of  the  brain  first,  and  to 
produce  congestion  as  a  secondary  action.  The  more  diffusible 
stimulants,  as  ether,  chloroform,  and  alcohol,  no  doubt  cause  a 
certain  amount  of  congestion  of  the  brain,  just  as  they  produce 
flushing  of  the  face  by  paralj^sing  the  sympathetic  ;  but  nitrite 
of  amyl  and  its  allies  appear  to  be  the  only  known  agents 
which  act  specially  on  the  vaso-motor  system  before  affecting 
the  tissue  of  the  cortex  of  the  brain. 

The  cerebral  symptoms  in  hyperpyrexia  and  insolation  were 
at  one  time  referred  to  congestion  of  the  brain  ;  but  it  is  much 
more  probable  that  the  high  temperature  acts  in  a  deleterious 
manner  on  the  cerebral  tissues.  The  cerebral  symptoms  of 
fevers  are  probably  due  quite  as  much  to  qualitative  as  to 
quantitative  alterations  of  the  blood  in  the  brain. 

Active  cerebral  congestion  appears  to  be  more  common  in 
males  than  in  females,  and  in  adults  than  in  either  the  old  or 
the  young.  The  statistics  of  Andral  and  of  Hammond  tend  to 
show  that  the  disease  is,  as  might  be  expected,  more  common 
in  winter  than  in  summer.  Heredity  undoubtedly  exercises 
some  influence  in  causing  cerebral  hypersemia,  but  it  is  pro- 
bable that  the  influence  is  indirect  rather  than  direct,  as  in  the 
gouty  diathesis. 

Passive  Congestion. — Venous  congestion  of  the  brain  may 
be  only  part  of  venous  congestion  of  the  whole  body,  or  it  may 
be  produced  by  special  causes.  General  venous  congestion  is 
caused  by  diseases  of  the  heart  and  lungs ;  and  for  the 
mechanism  by  which  this  congestion  is  brought  about  the 
reader  is  referred  to  works  devoted  to  diseases  of  these  organs. 

Congestion  is  also  caused  by  all  local  diseases  which  retard 
the  return  of  blood  from  the  brain. 

§  775.  Symptoms. — Congestion  of  the  .brain  gives  rise  to 
symptoms  which  vary  widely  in  different  cases ;  but  for  clinical 
purposes  three  varieties  may  be  described — (a)  the  slight,  (b) 
the  severe,  and  (c)  the  apoplectic  form. 


696  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

{a)  In  the  slight  form  of  congestion  the  prominent  symptoms 
are  sensory  disorders.  The  patient  complains  of  severe 
headache,  either  deep-seated  or  lancinating,  aggravated  by 
movement,  light,  sound,  or  heat,  while  all  intellectual  efforts 
become  impossible.  '  Patients  at  the  same  time  complain  of 
dizziness,  tinnitus  aurium,  and  optical  illusions.  Sleeplessness 
is  an  early  and  important  symptom.  It  is  accompanied  by 
restlessness  and  agitation;  and  if  sleep  do  supervene,  it  is 
disturbed  by  horrible  dreams,  and  the  patient  awakes  un- 
refreshed  without  relief  to  the  headache. 

In  the  arterial  variety  of  congestion  the  patients  are  fret- 
ful, restless,  and  excitable;  but  although  they  avoid  mental 
exertion  for  fear  of  aggravating  their  sufferings,  their  intel- 
lectual faculties  are  not  impaired ;  on  the  contrary,  there  may 
be  excessive  mental  activity.  There  may  be  some  numbness 
and  formication  of  the  extremities,  but  there  are  no  motor 
disorders.  There  is  generally  obstinate  constipation.  This 
form  of  congestion  frequently  occurs  in  plethoric  subjects. 
The  slightest  exciting  cause,  such  as  a  full  meal  after  a 
prolonged  fast,  or  unusual  mental  fatigue,  often  suffices  to 
induce  an  attack,  which  may  last  for  a  few  hours  only  or 
persist  for  some  days. 

In  the  venous  variety  of  hypersemia  the  phenomena  of  mental 
depression  are  usually  more  marked  than  those  of  excitement. 
There  is  a  dull  sense  of  oppression  in  the  head,  the  face  is  livid, 
there  are  mental  torpor  with  a  tendency  to  sleep,  and  a  certain 
amount  of  confusion  of  ideas,  especially  on  awaking  after  a 
short  sleep. 

(6)  In  the  severe  forms  other  symptoms  are  added.  The 
patient  suffers  so  much  from  vertigo  that  he  is  unable  to  main- 
tain the  erect  posture,  and  sudden  vomiting  may  occur  in  the 
absence  of  any  gastric  irritation  to  account  for  it.  The  pulse 
is  slow,  full,  and  hard;  the  arteries  of  the  head  and  neck  beat 
forcibly;  the  face  is  frequently,  although  not  always,  flushed,  and 
may  at  times  be  livid,  while  a  sensation  of  flying  heat  shoots 
over  the  head  and  neck.  The  pupils  are  generally  contracted, 
and  there  is  some  degree  of  intolerance  of  light  and  sound. 
The  patient  complains  of  intense  headache,  and  is  the  subject 
of  hallucinations  and  illusions  which  pervert  the  judgment,  and 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  697 

may  lead  to  strange  and  disorderly  acts.  He  sometimes  en- 
deavours to  quit  his  bed,  and  to  pursue  or  run  away  from 
imaginary  objects;  he  is  loquacious  or  bursts  into  a  flood  of 
tears,  and  struggles  with  and  tries  to  escape  from  his  atten- 
dants. After  some  hours  of  excitement  and  struggling  the  skin 
becomes  covered  with  sweat,  the  pulse  is  accelerated,  the  face 
of  a  deep  red  colour,  and  the  patient  presents  the  leading 
symptoms  of  encephalitis ;  the  thermometer  shows  that  the 
temperature,  if  at  all  altered,  is  only  slightly  above  the  normal. 
If  these  symptoms  persist  for  some  time,  the  phenomena  of 
excitement  are  succeeded  by  those  of  depression,  the  delirium 
gradually  gives  place  to  mental  torpor,  the  muscular  agitation 
is  replaced  by  muscular  relaxation,  the  respiration  becomes 
stertorous,  there  are  involuntary  evacuations,  and  the  patient 
falls  into  a  state  of  coma. 

In  some  cases,  especially  in  aged  people,  the  severe  form  of 
congestion  declares  itself  suddenly  during  the  night,  as  a  simple 
delirium  of  action.  The  patient  awakes,  does  not  know  where 
he  is,  gets  up  and  performs  various  disorderly  actions  of  which 
he  has  no  knowledge.  In  the  morning  he  is  quiet  and  sensible, 
but  is  sad,  morose,  and  depressed ;  and  these  phenomena  may 
be  repeated  for  several"  consecutive  nights,  but  it  generally 
ends  at  last  in  an  attack  of  delirium  similar  to  that  which  has 
been  just  described.  An  abundant  secretion  from  the  con- 
junctiva and  mucous  membrane  of  the  mouth  is  said  to  be  a 
frequent  symptom  of  congestion  of  the  brain  in  old  people 
(Durand-Fardel.) 

Convulsions  are  the  most  frequent  and  most  striking  symp- 
toms of  cerebral  congestion  in  infants.  It  must  not,  however, 
be  thought  that  cerebral  congestion  always  accompanies  the 
convulsions  of  children.  It  is  indeed  probable  that  convulsions 
from  congestion  of  the  brain  in  children  are  rare  in  comparison 
with  those  which  are  secondary  to  other  diseases.  The  symptoms 
of  the  cerebral  congestion  of  infancy  are  similar  in  many 
respects  to  those  of  meningitis.  Both  are  attended  with  partial 
or  general  convulsions,  headache,  contraction  of  the  pupils, 
vomiting,  and  constipation.  The  course  of  the  two  affections, 
however,  enables  them  to  be  readily  distinguished.  In  conges- 
tion the  child  has  been  in  good  health  up  to  the  beginning  of 


698  DIFFUSED  DISEASES   OF   THE   ENCEPHALON. 

the  attack,  there  is  little  or  no  elevation  of  temperature,  and  the 
disease  terminates  in  recovery  in  two  or  three  days  at  most, 

(c)  The  apoplectic  form  is  characterised  by  sudden  and  total 
loss  of  consciousness  and  complete  resolution  of  the  limbs,  but 
reflex  excitability  is  preserved.  The  patient  recovers  conscious- 
ness in  a  few  hours,  and  after  a  short  time,  two  or  three  days 
at  most,  all  the  symptoms  disappear  without  leaving  a  trace 
behind.  Sometimes,  however,  after  complete  restoration  to  con- 
sciousness, a  certain  amount  of  muscular  paralysis  remains  in 
one  limb,  or  assumes  the  hemiplegic  form  and  persists  for  some 
time. 

§  776.  Morbid  Anatomy. — It  is  necessary  to  be  on  one's 
guard  against  certain  causes  of  error  with  respect  to  post- 
mortem appearances.  Both  arterial  and  venous  hypersemia 
may  disappear  at  death  without  leaving  a  trace  behind.  On 
the  other  hand,  when,  as  is  usually  the  case,  the  body  is 
laid  on  its  back,  a  large  quantity  of  blood  may  be  found  in 
the  veins  and  sinuses  of  the  occipital  fossse,  caused  by  the 
influence  of  gravity  after  death,  aided  probably  by  hypostatic 
congestion  during  the  last  few  hours  of  death.  The  act  of 
dying  by  respiratory  paralysis  may  also  cause  a  hypersemia  of 
the  cerebral  veins  when  there  were  no  symptoms  of  congestion 
during  the  course  of  the  disease. 

In  pathological  hypersemia,  when  the  calvarium  is  removed, 
the  vessels  of  the  diploe  are  frequently  found  congested.  The 
veins  of  the  dura  and  pia  mater  are  prominent  and  full  of  blood, 
and  so  also  are  the  choroid  plexuses  and  sinuses.  In  the 
severer  forms  of  congestion  the  brain  is  swollen,  and  the  gyri 
are  flattened  from  compression.  The  grey  substance  is  of  a 
dark  red  colour,  its  consistence  is  increased,  and  the  cut  surface 
of  the  white  substance  presents  a  large  number  of  red  points, 
from  which  drops  of  blood  exude.  The  white  substance  may  be 
of  a  yellowish-red  colour,  while  at  other  times  its  colour  is  little 
altered. 

In  chronic  congestion  the  vessels  themselves  become  altered. 
In  the  venous  variety  the  veins,  especially  those  of  the  mem- 
branes, the  surface  of  the  brain,  choroid  plexuses,  and  velum 
interpositum  are  enlarged  and  tortuous.      In  chronic  arterial 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.        ♦       699 

congestion  the  coats  of  the  arterioles  become  hypertrophied,  and 
the  smaller  vessels  may  present  visible  openings  after  section  ; 
miliary  aneurisms  are  often  discovered  by  careful  examina- 
tion, while  a  certain  amount  of  pigment  is  found  in  the  peri- 
vascular spaces.  In  very  chronic  cases  oedema  of  the  pia  mater 
and  of  the  choroid  plexuses  is  found  along  with  increase  of  the 
ventricular  fluid,  while  the  brain  itself  may  undergo  a  certain 
degree  of  atrophy.  The  ^tat  crihU  of  Durand-Fardel  consists 
of  a  sieve-like  appearance  of  the  brain  caused  by  the  round  or 
oval  openings  of  the  vessels,  some  of  which  are  as  large  as  a 
pin's  head.  These  openings  are  supposed  by  some  pathologists 
to  depend  upon  dilatation  of  the  perivascular  lymph-sheaths. 
They  are  commonly  found  at  the  autopsies  of  elderly  people  who 
have  suffered  for  a  long  time  from  cerebral  congestion. 

§  777.  Morbid  Physiology. — In  the  first  stages  of  active 
general  congestion  the  increased  quantity  of  blood  within  the 
cavity  of  the  skull  is  compensated  by  displacement  of  a  corre- 
sponding quantity  of  cerebro-spinal  fluid,  but  congestion  beyond 
a  certain  degree  must  augment  the  intracranial  pressure,  as  may 
be  readily  proved  to  occur  in  children  by  the  increased  tension  of 
the  anterior  fontanelle.  During  the  first  stage  of  active  conges- 
tion the  increased  supply  of  blood  to  the  organ  must  increase  its 
functional  activity,  thus  explaining  the  irritative  symptoms  ob- 
served at  the  onset  of  the  disease.  On  the  other  hand  increase 
of  the  intracranial  pressure,  beyond  the  point  at  which  it  is 
compensated  by  the  cerebro-spinal  fluid,  must  compress  the 
substance  of  the  brain,  and  so  give  rise  to  the  phenomena  of 
depression  observed  in  the  second  stage  of  congestion. 

In  the  apoplectic  form  of  congestion,  attended  by  uncon- 
sciousness and  subsequent  paralysis,  it  is  probable  that  a  serous 
transudation  takes  place  into  the  interstices  of  the  tissues. 
In  venous  hypergemia  the  blood  pressure  is  transferred,  so  that 
increase  of  venous  implies  a  diminution  of  arterial  tension  along 
with  a  superabundance  of  carbonic  acid  and  a  deficiency  of 
oxygen,  conditions  which  tend  to  narcotise  the  brain.  The 
conditions  present,  therefore,  combine  to  produce  the  pheno- 
mena of  depression  and  not  those  of  excitement;  and  the  few 
symptoms  which  simulate  those  of  increased  excitement,  such 


700       '       DIFFUSED   DISEASES   OF   THE   ENGEPHALON. 

as  sleeplessness,  restlessness,  and  mental  irritability,  are  those 
which  occur  in  imperfectly  nourished  brains  or  in  cerebral 
anaemia. 

§  778.  Diagnosis. — The  thermometer  may  be  of  use  in  dis- 
tinguishing hypersemia  from  inflammatory  diseases  of  the  brain, 
but  its  indications  are  not  to  be  too  implicitly  relied  upon. 
Congestion  may  be  distinguished  from  focal  disease  by  the 
absence  of  the  usual  symptoms  of  a  localised  lesion.  The  apo- 
plectic form  of  congestion  is  distinguished  from  true  apoplexy 
by  the  transitory  nature  of  the  symptoms  in  the  former,  but  it 
must  be  acknowledged  that  rupture  of  a  blood-vessel  in  some 
parts  of  the  brain  may  give  rise  to  symptoms  which  closely 
resemble  those  of  congestion. 

The  form  of  congestion  attended  with  delirium  may  be  mis- 
taken for  delirium  tremens ;  but  the  two  diseases  may  be 
distinguished  by  a  knowledge  of  the  habits  of  the  patient,  and 
the  circumstances  which  have  preceded  the  attack.  At  the 
same  time  the  trembling  of  the  lips  and  hands,  the  skin 
bathed  in  perspiration,  the  soft  compressible  pulse,  the  timid 
and  frightened  look,  and  the  busy  character  of  the  delirium 
form  a  group  of  symptoms  so  characteristic  that  it  is  difficult 
for  a  practised  eye  to  mistake  the  alcoholic  disease  for  any 
other.  A  certain  kind  of  delirium  may  be  caused  by  lead 
poisoning,  which  may  simulate  that  from  congestion ;  but  the 
two  may  be  distinguished  by  the  history  of  the  case  and  by  the 
condition  of  the  gums. 

The  respiratory  movements  and  the  pulse  are  retained  in 
greater  integrity  in  congestive  apoplexy  than  in  syncope.  The 
coma  which  succeeds  an  epileptic  attack  may  be  mistaken  for 
the  coma  of  the  apoplectic  form  of  congestion.  These  affections 
must  be  distinguished  mainly  by  the  history  of  convulsions, 
and  by  the  fact  that  the  tongue  is  often  bitten  during  the 
epileptic  attack. 

The  lighter  forms  of  congestion  may  be  mistaken  for  gastric 
vertigo,  or  for  the  vertigo  which  is  caused  by  venereal  excess. 
Gastric  vertigo  is  associated  with  some  forms  of  dyspepsia,  it 
often  diminishes  or  ceases  after  food,  and  is  accompanied  by 
nausea. 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.        -        701 

After  having  determined  that  the  symptoms  are  caused  by- 
cerebral  hypersemia,  it  is  then  necessary  to  decide  whether  the 
congestion  be  arterial  or  venous,  and  whether  it  be  primary  or 
secondary.  A  careful  examination  of  the  lungs,  heart,  and 
blood-vesse;ls,  and  the  condition  of  the  urine,  will  enable  us  to 
decide  whether  any  mechanical  condition  is  present  which 
would  cause  venous  or  arterial  congestion.  If  none  of  these 
conditions  be  present,  then  the  congestion  must  be  regarded  as 
active,  and  its  prihiary  or  secondary  nature  will  be  revealed 
by  a  knowledge  of  its  cause.  The  most  ordinary  causes  of 
primary  congestion  are  insolation,  unwonted  mental  efforts, 
wakefulness,  and  excess  in  eating ;  while  the  most  ordinary 
causes  of  secondary  congestion  are  gout,  rheumatism,  suppres- 
sion of  the  menses  and  other  habitual  discharges,  and  cerebral 
lesions,  as  tumours  of  the  encephalon. 

§  779.  Course  and  Prognosis. — Great  differences  exist  in  the 
severity  and  duration  of  cerebral  congestion.  The  severer 
forms  may  cause  death,  and  even  the  lighter  forms,  if  they  do 
not  present  any  immediate  danger,  are  apt  to  recur  and  to 
produce  permanent  bad  effects. 

The  prognosis  in  the  severer  forms  of  congestion  is  grave, 
and  when  delirium  is  present  the  case  often  terminates  in 
hgemorrhage. 

Cerebral  congestion  is  most  dangerous  in  old  people,  because 
the  degenerated  vessels  are  apt  to  rupture. 

In  cases  of  chronic  disease  of  the  brain,  as  tumour  or  vascular 
degeneration,  cerebral  congestion  may  aggravate  the  symptoms 
or  prove  the  immediate  cause  of  death. 

§  780.  Treatment. — The  treatment  of  cerebral  congestion 
will  vary  according  as  its  cause  is  found  in  general  plethora, 
organic  diseases  of  the  heart,  vaso-motor  disturbances,  or  a  pre- 
existing focus  of  disease  in  the  brain. 

During  the  attack  the  patient  should  lie  in  bed  with  the 
upper  part  of  the  body  raised,  the  room  darkened,  and  the 
utmost  quiet  enjoined.  If  delirium  be  present  and  the  patient 
of  a  plethoric  habit,  a  small  quantity  of  blood  may  be  drawn 
from  the  arm,  followed  by  the  administration  of  a  saline  pur- 
gative. 


702  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

In  the  congestion  of  the  brain  caused  by  suppression  of  the 
menses,  or  of  hsemorrhoidal  discharge,  leeches  may  be  applied 
to  the  anus  or  to  the  upper  part  of  the  thigh,  and  be  followed 
by  a  smart  purgative.  Aloes,  or  aloes  in  combination  with 
sulphate  of  magnesia,  is  very  useful  in  these  cases. 

In  the  treatment  of  active  congestion  with  irritative  symptoms 
from  such  causes  as  insolation  and  excessive  fatigue  general 
bleeding  is  no  longer  permissible,  and  the  main  reliance  must 
be  placed  upon  saline  or  other  hydragogue  jiurgatives,  mustard 
pediluvia,  and  cold  steadily  applied  to  the  head  by  means  of 
an  ice  bag  or  evaporating  lotions.  If  the  patient  be  of  a  gouty 
constitution,  a  saline  mixture  with  colchicum  may  be  ad- 
ministered after  the  bowels  have  been  acted  upon.  Aconite  is 
a  useful  remedy  in  many  cases. 

The  diet,  of  course,  must  be  plain  and  unstimulating  during 
the  attack.  In  venous  congestion  a  small  bleeding  may 
occasionally  be  advisable,  inasmuch  as  the  lowering  of  the  ten- 
sion within  the  veins  permits  the  arterial  blood  to  pass  more 
freely  through  the  capillaries,  and  the  tissues  become  better 
nourished.  The  main  reliance  in  the  treatment  of  venous 
hypergemia  of  the  brain  must  be  placed  upon  drastic  purgatives, 
diuretics,  and  cardiac  tonics  as  digitalis.  Those  who  have  once 
suffered  from  one  or  more  attacks  of  active  cerebral  congestion 
should  adopt  certain  hygienic  precautions  to  prevent  a  repetition 
of  the  attack.  Their  diet  should  be  plain,  consisting  in  large 
part  of  herbaceous  vegetables  and  fruits,  and  all  stimulants,  as 
wine,  tea,  and  coffee,  should  be  proscribed.  They  should  avoid 
everything  tending  to  cause  mental  excitement,  such  as  public 
speaking,  theatres  and  concerts,  intellectual  efforts,  late  hours, 
and  venereal  excess. 


703 


CHAPTER    XI. 


II.    DIFFUSED  DISEASES  OF  THE  ENCEPHALON  (Continued). 


(II.)  ATROPHY  AND  HYPERTROPHY  OF  THE  BRAIN. 
(i.)  Atrophy  of  the  Brain. 
§  781.  Atrophy  of  the  Corpus  CallosuTYi. — The  corpus  cal- 
losum  begins  to  develop  towards  the  end  of  the  fourth  month 
of  intra-uterine  life  by  the  outgrowth  of  two  lateral  stumps 
from  the  internal  surface  of  the  hemisphere  vesicles.  These 
grow  towards  one  another,  and  unite  between  the  sixteenth 
and  twentieth  weeks  of  intra-uterine  life,  the  union  taking 
place  from  before  backwards.  The  development  of  the  corpus 
callosum  may  be  arrested  at  any  period,  so  that  it  may  be 
entirely  wanting,  or  it  may  grow  on  each  side  to  nearly  the 
normal  size,  but  union  fails  to  take  place  in  the  middle  line. 
At  other  times  the  union  may  be  partial  and  the  corpus  cal- 
losum be  represented  by  a  rudimentary  bridge,  or  sieve -like 
plate  of  tissue.  When  the  corpus  callosum  is  entirely  wanting, 
its  radiating  fibres  are  also  absent,  the  cavities  of  the  lateral 
ventricles  are  unusually  large,  they  are  at  the  same  time  filled 
with  serous  fluid,  the  ependyma  is  granular  and  thickened,  and 
the  choroid  plexuses  are  generally  found  diseased. 

§  782.  Symptoms. — Congenital  deficiency  of  the  corpus  cal- 
losum has  generally  been  found  associated  with  idiocy,  or  at  least 
with  some  degree  of  mental  deficiency.  The  mental  defects  in 
such  cases  do  not  present  anything  characteristic,  so  that  this 
condition  cannot  be  recognised  during  life.  Some  cases  of 
arrest  of  development  of  the  corpus  callosum  have,  however, 
been  reported  in  which  no  marked  mental  deficiency  was  ob- 
served during  life  (Paget,  Jolly,  Malinverni,  Eichler). 


704  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

§  783.  Atrophy  of  the  Cerebellum. — Slight  degrees  of  atrophy- 
are  often  observed,  either  as  complicatioDS  of  cerebral  diseases, 
or  as  consequences  of  diseased  foci  in  the  organ  itself,  but  these 
lesions  cannot  be  recognised  during  life.  Cases  of  uncompli- 
cated atrophy  of  the  cerebellum  are  rare,  but  the  few  which 
have  been  observed  are  important  from  the  light  they  throw  on 
the  functions  of  the  organ. 

§  784.  Etiology. — In  the  cases  reported  by  Lallement  and 
Otto,  and  probably  also  to  some  extent  in  Combette's  case,  the 
atrophy  was  congenital.  In  a  case  reported  by  Meynert  and 
another  by  Pierret,  fright  is  assigned  as  the  cause.  In  Clapton's 
case  the  nervous  symptoms  appeared  after  measles,  and  gradaully 
diminished  in  severity. 

§  785.  Symptoms.—  The  following  were  the  symptoms  in 
Combette's  case :  The  girl  Labrorse  at  12  years  was  weak- 
minded  and  suffered  from  epileptic  attacks.  She  could  not 
stand  or  walk  until  five  years  old.  At  seven  her  lower  ex- 
tremities were  feeble,  and  she  often  fell.  During  the  last  three 
months  of  life  she  was  bedridden  and  could  scarcely  move  her 
legs,  and  her  articulation  was  imperfect. 

Motor  disturbances  were  observed  in  the  cases  reported  by 
Meynert,  Pierret,  Fiedler,  Clapton,  Dugnet,  and  Moreau.  Most 
authors  describe  these  as  those  of  ataxia;  while  others  state 
that  the  patients  could  walk,  but  only  slowly  and  carefully ; 
that  they  fell  frequently,  especially  backwards;  and  that  in 
walking  they  seized  hold  of  objects  within  their  reach.  All 
these  patients  had  also  either  persistent  or  temporary  dis- 
turbance of  speech. 

No  motor  disturbance  was  noticed  by  Lallement  and  Otto. 
Otto's  patient  was  impulsive  in  his  movements,  but  whether 
due  to  psychical  causes  or  disturbance  of  co-ordination  could 
not  be  determined. 

Weakness  of  mind,  even  idiocy,  characterised  the  patients  of 
Clapton,  Otto,  and  Fiedler ;  while  Pierrot's  case  suffered  from 
weakness  of  memory. 

Epileptiform  convulsions  are  frequently  mentioned,  but  do 
not  appear  to  have  any  special  significance. 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  705 

Symptoms  occasionally  noticed  are  analgesia  (Fiedler)  and 
slight  disturbances  of  sensibility  (Pierret). 

§  786.  Morbid  Anatomy, — In  Combette's  case  the  entire 
organ  had  disappeared.  There  was  no  trace  of  a  pons,  although 
the  cerebral  arteries  were  present  and  of  normal  size.  In  other 
reported  cases  the  cerebellum  has  been  found  reduced  to  about 
half  the  normal  size. 

Lallement  mentions  a  case  in  which  the  left  lobes  of  the 
cerebellum,  including  its  middle  and  superior  peduncles,  was 
reduced  to  the  size  of  a  nut,  and  the  transverse  fibres  of  the 
pons,  the  right  corpus  striatum,  and  the  right  olivary  body  were 
atrophied.  In  Dngnet's  case  the  cerebellum  was  about  half 
the  normal  weight.  The  atrophy  was  bilateral  and  general, 
and  the  substance  of  the  organ  showed  well-marked  sclerosis. 
Somewhat  similar  cases  have  been  reported  by  Clapton  and 
Fiedler-Bergmann.  No  statement  is  made  with  regard  to  the 
condition  of  the  pons. 

Meynert  describes  a  similar  degeneration  in  the  pons,  which 
he  regards  as  a  secondary  degeneration,  and  not  as  the  starting 
point  of  the  affection.  The  cerebellum  itself  was  much  altered, 
especially  on  the  right  side.  The  posterior  pyramids  of  the 
medulla  were  implicated  as  well  as  the  pons  and  the  crus 
cerebelli  ad  pontem.  In  Pierret's  case  there  was  an  intense 
degree  of  sclerotic  atrophy,  which  affected  chiefly  the  vertical 
diameter  of  the  organ,  the  grey  substance  being  specially 
affected.  The  transverse  fibres  of  the  pons  and  both  olivary 
bodies  were  atrophied  and  replaced  by  connective  tissue.  In 
Otto's  case  the  left  lobe  was  the  more  atrophied,  and  the  pons 
on  the  left  side  was  narrower  than  on  the  right.  The  space 
usually  occupied  by  the  cerebellum  was  replaced  by  hyperostosis 
of  the  occipital  bone. 

§  787.  Complications  and  Diagnosis. — Atrophy  of  the 
lateral  lobe  of  the  cerebellum  has  been  found  associated  with 
atrophy  of  the  transverse  fibres  of  the  pons  on  the  same  side, 
and  with  atrophy  of  the  olivary  body  and  cerebral  hemisphere 
on  the  opposite  side.  In  some  few  cases  the  atrophy  of  the 
cerebrum  and  cerebellum  occurs  on  the  same  side. 

TT 


706  DIFFUSED   DISEASES   OF  THE   ENCEPHALON, 

Atrophy  of  the  cerebellum  is  difficult  to  distinguish  from 
chronic  affections  of  the  organ,  but  headache  and  vomiting, 
which  are  common  in  the  latter,  are  rare  in  the  former.  The 
sensory  and  reflex  disturbances  of  locomotor  ataxia  serve  to 
distinguish  it  from  atrophy  of  the  cerebellum.  The  symp- 
toms of  the  initial  stage  of  insular  sclerosis  may  be  similar  to 
those  of  atrophy  of  the  cerebellum,  but  when  the  characteristic 
tremors  of  the  former  appear  the  diagnosis  is  easy. 


(ii.)   Htperteopht  of  the  Bkain. 

Hypertrophy  of  the  brain  includes  several  different  morbid 
conditions.  It  is  also  usual  to  include  along  with  hypertrophy  a 
new  formation  of  cerebral  substance  within  the  substance  of  the 
brain  itself,  a  condition  which  Yirchow  has  called  Heterotopia 
of  the  brain.  Hypertrophy  may  be  divided  into  general  and 
partial  hypertrophy. 

§  788.  Etiology. — Hypertrophy  of  the  brain  appears  to  be 
generally  congenital.  Several  of  the  reported  cases  were 
associated  with  peripheral  multiple  neuroma  (Hesselbach, 
Hitchcock,  Betz),  and  both  of  these  conditions  are  frequent 
accompaniments  of  idiocy  or  delayed  mental  development. 
The  affection  is  almost  always  developed  soon  after  birth  or 
in  early  infancy.  A  few  cases  appear  to  have  developed  sub- 
sequently to  an  injury  to  the  head  (Tuke,  Dance),  while  the 
disease  appears  to  have  been  a  result  of  chronic  lead  poisoning 
(Andral,  Laennec,  Bright). 

Symptoms.  —  Severe  headache,  with  remissions  or  even 
complete  intermissions,  is  a  prominent  symptom  of  hyper- 
trophy of  the  brain.  Epileptiform  convulsions,  local  spasms, 
attacks  of  laryngismus  stridulus,  and  tremors  are  also  com- 
monly observed.  The  pulse  is  usually  retarded,  but  it  may 
occasionally  be  much  accelerated  (Steiner).  The  symptoms  of 
chronic  cerebral  hypertrophy  are  not  well  known.  The  affec- 
tion in  children  is  sometimes  associated  with  premature  develop- 
ment (Elliotson),  or  at  least  a  degree  of  development  corre- 
sponding to  their  age.     In  other  cases,  again,  there  is  more  or 


DIFFUSED   DISEASES   OF  THE   ENCEPHALON.  707 

less  weakness  of  mind,  amounting  even  to  the  highest  degree  of 
idiocy.  The  tongue  is  often  increased  in  size,  and  often  pro- 
trudes from  the  mouth.  Drowsiness  is  an  occasional  but  by 
no  means  constant  symptom.  Some  of  the  affected  children 
are  liable  to  fall  frequently,  being  over-balanced  by  the  great 
weight  of  the  head.  Disturbances  of  the  nerves  of  the  general 
or  special  senses  are  comparatively  rare.  The  optic  nerve  in 
particular  is  seldom  mentioned ;  Steiner  and  Neurenthar  alone 
speak  of  the  sudden  occurrence  of  blindness,  others  mention 
photophobia.  A  careful  ophthalmoscopic  examination  of  the 
optic  discs  might  have  given  more  positive  results.  Tinnitus 
and  subjective  noises  in  the  head  are  sometimes  present.  Death 
often  results  from  an  attack  of  convulsions,  or  in  coma  due  to 
cerebral  compression,  while  many  of  those  affected  die  from 
some  intercurrent  disease. 

§  789.  Morbid  Anatomy. — The  anatomical  appearances  differ 
according  as  the  hypertrophy  is  partial  or  general. 

General  hypertrophy  begins  in  the  earlier  years  of  child- 
hood, and  the  skull  enlarges  just  as  in  hydrocephalus.  If  the 
disease  appear  for  the  first  time  after  the  bones  of  the  skull 
have  become  ossified,  the  bones  are  subjected  to  compression 
from  within  and  undergo  atrophy  at  certain  points.  It  is 
probable  that  this  condition  is,  however,  connected  with  the 
changes  which  the  cranial  bones  are  known  to  undergo  in 
congenital  syphilis. 

The  cerebral  membranes  are  generally  compressed  against 
and  become  adherent  to  each  other  and  to  the  bones  of  the 
skull.  The  membranes  are  thin,  their  blood-vessels  are  scarcely 
visible,  and  every  trace  of  cerebral  spinal  fluid  is  absent. 

The  lateral  ventricles  are  compressed  so  that  they  either 
contain  no  fluid,  or  only  a  small  amount.  The  convolutions  are 
flattened  and  so  pressed  together  that  the  sulci  seem  entirely 
obliterated.  The  brain  substance  shows  a  marked  change  of 
consistency ;  it  is  tough,  like  boiled  white  of  egg  or  cheese. 
Tuke  could  make  no  impression  on  it  by  a  column  of  water 
five  feet  high. 

The  brain  is,  as  a  rule,  found  anaemic  on  section,  and  the  grey 
substance  so  pale  that  it  differs  little  from  the  white.     This 


708  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

extreme  anaemia,  however,  appears  to  be  a  terminal  phenomena 
due  to  the  increased  compression. 

The  average  weight  of  the  brain  in  adults  is,  according  to 
Huschke,  from  1,500  to  1,600  grammes ;  although  the  weight 
of  the  brains  of  persons  prominent  in  literature  has  considerably 
exceeded  2,000  grammes.  The  absolute  weight  of  the  brain, 
considered  without  reference  to  its  density  and  other  circum- 
stances, only  warrants  the  diagnosis  of  hypertrophy  when  the 
average  is  considerably  exceeded. 

The  specific  gravity  of  the  cerebral  mass  should  also  be  taken 
into  account.  Tuke  found  the  specific  gravity  unchanged  on 
the  diseased  side  in  his  case  of  unilateral  hypertrophy,  being 
1,036  on  both  sides,  but  the  result  differed  from  that  obtained 
with  normal  brains  in  the  fact  that  it  was  the  same  in  the  grey 
as  in  the  white  substance. 

The  cerebrum  is  as  a  rule  alone  affected  with  hypertrophy, 
but  there  are  a  few  cases  in  which  the  cerebellum  also  is  said 
to  have  been  affected  (Sweatmann). 

Yirchow  attributes  the  increased  size  of  the  brain  to  hyper- 
plasia of  the  neuroglia. 

Partial  hypertrophy  is  rarer  than  the  general  form  of  the 
affection,  and  even  some  of  the  reported  cases  are  not  beyond 
suspicion,  inasmuch  as  gliomatous  tumours  were  probably 
mistaken  for  partial  hypertrophy  of  the  brain.  Hesselbach 
mentions  the  case  of  a  man  who  inherited  the  disease  from  his 
father,  and  who,  besides  multiple  neuromata  of  the  peripheral 
nerves,  presented  a  considerable  enlargement  of  the  sympathetic 
ganglia,  and  of  one  of  the  middle  cerebellar  peduncles. 

§  790.  Course. — It  is  very  difficult  in  many  cases  to  estimate 
the  duration  of  the  disease,  inasmuch  as  even  in  the  cases  which 
appear  to  be  primarily  acute  the  course  may  actually  have  been 
protracted,  the  disease  being  latent  until  the  space  in  the 
cranium  became  limited.  Many  chronic  cases  suddenly  assume 
an  acute  character,  and  terminate  quickly  in  death.  The  fatal 
termination  is  often  caused  by  an  intercurrent  disease,  such  as 
diarrhoea  or  bronchitis. 

Chronic  cases  may  extend  over  many  years,  the  disease 
apparently  remaining  stationary.    A  sudden  increase  in  volume, 


DIFFUSED  DISEASES   OF  THE   ENCEPHALON.  709 

whether  in   a    brain   previously   healthy   or   in    one   already 
chronically  enlarged,  may  cause  rapid  death. 

Acute  hypertrophy  produces  the  symptoms  common  to  all 
diseases  causing  compression  of  the  brain ;  while  the  chronic 
form,  especially  in  children,  can  scarcely  be  distinguished  from 
chronic  hydrocephalus. 

§  791.  Diagnosis,  Prognosis,  and  Treatment. — The  diagnosis 
is  always  uncertain,  but  the  possibility  of  this  condition  ought 
certainly  to  be  borne  in  mind  before  puncturing  a  hydrocephalic 
head.  The  prognosis  is  always  unfavourable,  but  on  account  of 
the  impossibility  of  making  a  diagnosis  a  prognosis  cannot  well 
be  given.     No  treatment  is  of  any  avail. 

§  792.  Heterotopia  of  Brain  Substance. — This  condition  was 
first  described  by  Virchow,  and  has  hitherto  been  principally 
of  interest  to  the  morbid  anatomist.  Simon  found  small  acces- 
sory gyri  situated  on  the  summit  of  the  convolutions.  Virchow 
observed  in  one  case  an  apparently  new  formation  of  gyri  within 
the  white  substance  of  the  posterior  lobe.  He  also  found  a 
hyperplastic  malformation  of  the  caudate  nucleus.  Klob  found 
a  mass  of  white  cerebral  substance,  the  size  of  a  bean,  hanging 
from  a  pedicle  between  the  optic  nerves. 

Microscopic  examination  of  the  heterotopic  grey  substance 
shows,  as  a  rule,  similar  elements  to  those  of  the  normal  cortex, 
but  the  ganglion  cells  in  the  former  are  pigmented  and  fatty. 

These  conditions  have  hitherto  been  found  in  epileptics, 
idiots,  or  in  persons  otherwise  mentally  affected,  but  their 
clinical  significance  is  somewhat  doubtful.  All  authors  regard 
these  malformations  as  congenital. 


I 


710 


CHAPTER    XII. 


II.  DIFFUSED  DISEASES  OF  THE  ENCEPHALON  (Continued). 


(III.)    SHOCK   AND    CONCUSSION, 
(i.)    Shock. 

§  793.  Definition. — Shock  results  from  profound  bodily  or 
mental  impressions,  and  appears  to  depend  upon  a  sudden  tem- 
porary impairment  or  permanent  extinction  of  the  functions  of 
the  nervous  system,  the  cardiac,  vaso-motor,  and  respiratory 
centres  in  the  medulla  oblongata  being  specially  affected. 

§  794.  Etiology. — Amongst  the  predisposing  causes  of  shock 
may  be  mentioned  constitutional  peculiarities  or  idiosyncrasies. 
Some  people  inherit  so  unstable  a  nervous  system  that  an  injury 
inappreciable  to  others  may  produce  in  them  all  the  phenomena 
of  shock.  The  irritability  of  the  nervous  system  is  greater  in 
youth  than  in  old  age,  and  consequently  the  phenomena  of 
shock  are  produced  by  slighter  causes  in  the  former  than  in  the 
latter.  The  recuperative  power,  on  the  other  hand,  is  greater 
in  youth  than  in  the  aged,  hence  the  phenomena  of  shock, 
although  less  obvious,  are  more  grave  in  the  latter  than  in  the 
former.  Shock  is,  as  a  rule,  more  easily  produced  in  the  female 
than  the  male  sex.  An  undue  irritability  of  the  nervous  system 
is  sometimes  acquired  rather  than  inherited,  and  all  conditions 
which  tend  to  impair  the  nutrition  of  the  nervous  system,  as 
exhausting  diseases,  cerebral  anaemia  from  whatever  cause 
arising,  dissipation,  prolonged  pain,  the  depressing  passions, 
predispose  to  the  production  of  shock.  During  the  stage  of 
depression  of  shock  the  irritability  of  the  nervous  system  is 
nearly  exhausted,  a  greater  resistance  is  thus  offered  to  the  con- 
duction of  impulses  from  the  periphery  to  the  higher  nerve- 


DIFFUSED   DISEASES  OF   THE   ENCEPHALON.  711 

centres,  and  consequently  during  this  stage  a  second  injury 
produces  a  much  less  effect  than  the  first.  During  the  stage  of 
reaction,  however,  the  irritability  of  the  nervous  system  is  ex- 
cessive, so  that  a  slight  stimulus  may  produce  a  profound  effect. 
In  persons  of  powerful  will  and  stable  nervous  systems  the 
effect  of  an  unexpected  injury  is  greater  than  if  the  patient 
were  prepared  for  its  reception ;  while  in  emotional  patients, 
with  unstable  nervous  systems,  previous  knowledge  of  an  im- 
pending injury  greatly  intensifies  its  effects.  Injuries  of  the 
abdominal  viscera,  genitals,  joints,  and  bones  produce  more 
profound  effects  than  injuries  of  other  parts  of  the  body. 

The  exciting  causes  of  shock  are  sudden  and  severe  or  ex- 
tensive injuries  of  any  part  of  the  body,  whether  produced  by 
accidental  wounds  or  burns,  or  by  surgical  operations.  Shock 
is  also  produced  by  strong  emotional  excitement  of  any  kind, 
although  the  depressing  passions,  as  fear  and  anger,  are  more 
liable  to  cause  it  than  pleasurable  passions,  like  joy. 

§  795.  SyTYiptoms. — Cases  of  shock  may  be  divided  clinically 
into  two  forms — (a)  cases  in  which  the  symptoms  of  depression 
predominate,  and  (6)  cases  in  which  the  symptoms  of  prostration 
are  mixed  with  those  of  excitement  (Travers,  Savory).  Dr. 
Lauder  Brunton  has  proposed  to  call  these  forms  respectively 
torpid  and  erethismic  shock. 

(a)  Torpid  Shock. — In  the  torpid  form  of  shock  the  patient 
lies  utterly  prostrate ;  the  surface  of  the  body  is  pale,  cold,  and 
covered  by  a  clammy  sweat,  which  collects  in  drops  on  the 
forehead  and  eyebrows ;  the  lips  are  bloodless,  the  nostrils 
dilated,  and  the  countenance  of  a  dull  aspect  and  shrunken, 
while  the  eyes  have  lost  their  lustre,  are  sunk  in  their  sockets, 
and  partially  concealed  by  the  drooping  lids.  There  is  complete 
muscular  relaxation,  which  may  even  extend  to  the  sphincters. 
If  the  patient  be  conscious,  he  may  complain  of  feeling  cold  and 
faint,  while  the  whole  body  may  tremble.  The  pulse  is  frequent, 
irregular,  unequal,  and  feeble  or  imperceptible  at  the  wrist, 
although  the  fluttering  action  of  the  heart  may  be  heard  on 
auscultation.  The  respiratory  movements  are  irregular  and 
gasping,  or  short  and  feeble,  the  respirations  being  sometimes 
so  superficial  that  they  are  scarcely  visible,  although  a  slight 


712  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

movement  of  the  diaphragm  may  generally  be  discovered  by 
careful  observation.  The  temperature  of  the  body  is  depressed. 
The  patient  suffers  from  vertigo  and  dimness  of  vision,  while  in 
the  less  severe  cases  there  is  nausea,  vomiting,  and  hiccough. 

The  psychical  symptoms  consist  of  mental  depression,  restless- 
ness, confusion  of  thought,  incoherence,  or  drowsiness,  although 
the  patient  generally  gives  rational  replies  to  definite  questions. 
At  other  times  the  patient  appears  singularly  calm  and  rational, 
while  the  various  senses  remain  unaffected,  hearing  being  some- 
times unusually  acute, 

(6)  Erethismnic  Shock. — This  form  of  shock  is  rare,  the 
majority  of  cases  in  which  symptoms  of  prostration  are  mixed 
with  those  of  excitement  being  preceded  by  a  distinct,  though 
it  may  be  transient,  stage  of  collapse.  The  skin  is  at  first  hot 
and  dry;  the  face  is  flushed  and  wears  an  anxious  expression ; 
the  pulse  is  frequent,  quick,  and  bounding,  but  always  com- 
pressible; the  respirations  are  hurried,  imperfect,  and  inter- 
rupted by  sighs;  the  tongue  is  tremulous;  and  the  patient 
complains  of  thirst,  rigors  are  occasionally  present,  while  vomiting 
is  a  frequent  and  sometimes  obstinate  symptom.  The  mental 
and  bodily  prostration  of  collapse  is  succeeded  by  tremor  and 
twitchings  of  the  muscles,  there  is  restlessness,  jactitation,  prse- 
cordial  anxiety,  and  delirium.  The  psychical  disturbances 
observed  are  somewhat  variable.  At  times  the  patient  merely 
presents  a  peculiar  irritability  of  manner,  with  an  increased 
disposition  to  talk,  sometimes  rationally,  occasionally  incohe- 
rently. At  other  times  the  patient  has  strange  illusions,  attended 
with  a  peculiar  dread  of  impending  evil.  In  some  cases,  how- 
ever, there  is  the  fiercest  maniacal  raving,  which  is  most  pro- 
nounced during  the  night,  or  the  delirium  may  assume  all  the 
characteristics  of  that  observed  in  delirium  tremens. 

The  patient  either  obtains  no  sleep,  or  it  is  partial,  inter- 
rupted, and  unrefreshing.  As  the  exhaustion  increases  the 
skin  becomes  covered  with  a  cold,  clammy,  and  often  profuse 
sweat.  The  face  becomes  pale  and  the  expression  haggard, 
the  pulse  is  frequent,  irregular,  fluttering,  and  uncountable. 
Subsultus  and  slight  convulsions  supervene,  and  the  patient 
dies  comatose. 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  713 

§  796.  Course,  Termination,  and  Duration. — The  degree  of 
shock  varies  greatly.  In  the  milder  forms  of  the  affection  the 
symptoms  are  chiefly  those  of  an  ordinary  fainting  fit.  Loss  of 
consciousness  is,  however,  a  more  marked  characteristic  of  syn- 
cope than  of  slight  shock,  whilst  recovery  from  the  former  is 
more  rapid  than  from  the  latter. 

In  the  severest  form  of  shock  the  functions  of  the  nervous 
system  are  suddenly  abolished,  and  the  heart  ceases  to  beat. 

Between  the  slighter  forms  of  shock,  which  resemble  an 
ordinary  fainting  fit,  and  the  severest  form,  which  terminates  in 
instantaneous  death,  innumerable  transitional  forms  may  be 
observed.  The  medium  degrees  of  shock  are  known  under  the 
name  of  collapse. 

The  slighter  degrees  of  shock  terminate  speedily  in  direct 
recovery,  while  the  severest  form  terminates  of  course  in  death. 
In  the  intermediate  forms  recovery  may  ultimately  take 
place,  but  it  is  preceded  by  a  stage  in  which  the  symptoms  of 
collapse  give  place  to  those  of  excitement,  this  stage  being  called 
the  period  of  reaction.  The  period  of  reaction  is  characterised 
by  improved  pulse  and  respirations,  restoration  of  muscular 
power,  and  increase  of  temperature.  Reaction  may  sometimes 
be  in  excess  and  febrile  symptoms,  supervene. 

The  symptoms  of  the  period  of  reaction  may  gradually  give 
place  to  health,  but  in  some  cases  relapses  are  not  unfrequent, 
and  convalescence  is  then  protracted.  In  other  cases  the  torpid 
may  be  replaced  by  the  erethismic  form  of  the  disease.  Re- 
covery from  severe  shock  is  often  partial  only,  the  irritability 
of  the  nervous  system  remains  permanently  increased,  a  con- 
dition which  predisposes  to  the  production  of  shock  from  the 
application  of  slight  exciting  causes. 

§  797.  Morbid  Anatomy. — No  definite  changes  have  been 
found  in  the  nervous  system  in  cases  of  shock.  All  the  cavities 
of  the  heart  are  usually  distended  with  blood  and  the  venous 
system  is  engorged.  Travers,  however,  relates  instances  of  death 
from  shock  when,  on  dissection,  both  sides  of  the  heart  were 
found  empty.  Dr.  A.  H.  Young  informs  me  that  he  has 
observed  cases  of  this  kind  in  the  post  mortem  room,  and  that 


714  DIFFUSED  DISEASES   OF   THE   ENCEPHALON. 

in  such  cases  the  abdomioal  veins-  have  not  unfrequently  been 
enormously  engorged  with  blood. 

§  798.  Morbid  Physiology. — In  its  widest  acceptation  shock 
is  the  sudden  impairment  or  abolition  of  the  functions  of 
protoplasm  by  the  application  of  an  excessive  stimulus.  The 
functions  of  the  protoplasm  of  all  the  organs  of  the  body  arfe 
doubtless  impaired  by  severe  injuries ;  but  in  the  higher  animals 
the  disorder  occasioned  in  the  functions  of  the  nervous  system 
becomes  so  predominant  that  the  direct  effects  of  injuries  on 
the  protoplasm  of  the  other  tissues  of  the  body  may  be  practi- 
cally disregarded.  The  most  striking  phenomena  of  shock  are 
those  which  cluster  around  the  organs  of  circulation.  The  ex- 
periments of  Goltz,  repeated  by  Brunton,  show  that  shock 
probably  results  from  cardiac  paralysis  and  vaso-motor  paralysis 
of  the  large  vascular  trunks  of  the  abdomen,  Brunton  states 
that  blows  of  moderate  severity  on  the  abdomen  of  frogs  pro- 
duce in  some  stoppage  of  the  heart,  without  dilatation  of  the 
abdominal  vessels,  and  in  others  vascular  dilatation,  without 
arrest  of  the  cardiac  pulsations,  while  severe  blows  generally 
produce  both  effects  simultaneously.  The  vessels  of  the  ab- 
domen are  so  large  that  when  fully  relaxed  they  are  capable 
of  containing  almost  all  the  blood  in  the  body,  and  con- 
sequently the  condition  resulting  from  their  rapid  dilatation 
IS  equivalent  to  a  sudden  haemorrhage.  This  double  con- 
dition of  cardiac  failure  and  vascular  dilatation  produces 
anemia  of  the  nerve-centres,  and  this  accounts  for  the  pallor 
and  coldness  of  the  surface  of  the  body,  and  the  weak,  com- 
pressible, and  fluttering  pulse.  It  must  not,  however,  be  for- 
gotten that  the  injury  which  has  disordered  the  functions  of  the 
vaso-motor  and  cardiac  centres  in  the  medulla  oblongata  must 
also  have  produced  a  direct  deleterious  effect  upon  other  nerve- 
centres.  The  disorders  of  respiration,  the  cries  of  pain,  and  the 
various  bodily  contortions  which  are  caused  by  bodily  injuries, 
or  severe  mental  excitement,  show  that  excessive  stimuli  occa- 
sion powerful  outgoing  discharges  from  the  higher  nerve-centres. 
But  a  powerful  discharge  from  a  nerve-centre  is  followed  by 
temporary  impairment  or  abolition  of  its  functions,  and  it  is  pro- 
bable that  the  arrest  of  the  functions  of  the  higher  nerve-centres, 


DIFFUSED  DISEASES   OF   THE   ENCEPHALON.  715 

caused  by  the  application  of  a  sudden  and  powerful  stimulus,  is 
the  most  important  factor  in  the  production  of  the  phenomena 
of  shock. 

The  symptoms  of  the  erethismic  variety  may  be  explained 
partly  on  the  supposition  that  the  nervous  tissues  are  in  the 
irritable  condition  frequently  observed  when  they  are  imper- 
fectly nourished,  and  partly  on  the  supposition  that  the 
phenomena  of  excitement  are  in  great  part  due  to  the  abolition 
of  the  functions  of  the  higher  nerve-centres,  thus  permitting  a 
greater  activity  of  the  lower  centres  to  take  place. 

§  799.  Diagnosis. — The  symptoms  of  shock  may  be  mistaken 
for  those  of  syncope,  but  the  former  are  more  protracted  than 
the  latter.  If  a  history  of  an  injury  or  of  the  presence  of  some 
other  exciting  cause  of  shock  can  be  ascertained,  the  diagnosis 
is  rendered  easy.  It  is  not  always  easy  to  distinguish  profound 
collapse  from  actual  death.  The  difficulty  can  only  arise  in 
those  rare  cases  of  collapse  in  which  the  action  of  the  heart 
ceases  to  be  heard  on  auscultation  and  the  respiratory  move- 
ments fail  to  be  detected,  or  powerful  cutaneous  irritants  cease 
to  excite  any  reflex  action.  The  most  certain  test  consists  of 
the  electrical  examination  of  the  muscles  and  nerves,  all  re- 
action in  them  ceasing  in  from  one  and  a  half  to  three  hours 
after  death. 

§  800.  Prognosis. — The  prognosis  depends  upon  the  degree 
of  shock,  and  the  constitution  of  the  patient.  Speaking 
broadly,  the  prognosis  is  the  more  favourable  the  less  the 
intensity  of  the  shock,  and  the  shorter  the  time  which  elapses 
before  reaction  takes  place. 

§  801.  Treatment. — The  treatment  of  shock  is  the  same 
generally  as  that  of  syncope,  the  great  aim  being  to  excite 
reaction.  It  must,  however,  be  constantly  borne  in  mind  that 
reaction,  once  excited,  is  apt  to  become  excessive.  In  the 
severer  forms  of  shock  the  heart  must  be  excited  to  action. 
The  mode  of  procedure  to  be  adopted  depends  upon  whether 
the  arrest  of  the  heart's  action  is  of  purely  nervous  origin, 
or   it   is   complicated   or  caused    by   great   haemorrhage.     In 


716  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

the  former  case  the  heart  is  probably  distended  and  the 
cervical  veins  engorged,  and  consequently  venesection  from 
the  external  jugular  veins  should  be  immediately  resorted  to 
(Savory)  ;  while  in  the  latter  condition  the  cavities  of  the 
heart  are  empty,  and  transfusion  of  blood  appears  to  be  the 
only  means  offering  a  chance  of  success.  In  any  case  warmth 
is  indicated,  and  the  patient  should  be  well  wrapped  up  in 
warm  blankets  and  surrounded  by  hot  bottles.  Stimulants 
must  now  be  given  internally,  brandy  being  generally  the 
readiest  and  best.  If  the  patient  be  unable  to  swallow, 
ammonia  or  ether  may  be  administered  subcutaneously,  or  the 
former  may  be  injected  into  a  vein,  or  a  stimulating  enema 
may  be  given.  Tincture  of  digitalis  may  be  administered  in 
half  drachm  doses,  but  its  action  is  much  too  slow  to  be  of 
much  use  in  the  early  stage  of  urgent  cases. 

(ii.)  Concussion, 
Concussion  is  a  special  form  of  shock,  the  disturbance  in  the 
functions  of  the  nervous  system  being  caused  by   direct  com- 
motion of  the  substance  of  the  brain. 

§  802.  Etiology. — The  exciting  causes  of  concussion  are 
severe  injuries,  as  falls  from  a  height  or  blows  on  the  head, 
which  cause  the  whole  mass  of  the  encephalon  to  be  jolted  or 
shaken.  Concussion  may  be  complicated  by  fracture  of  the 
skull,  and  in  such  cases  the  effects  of  the  concussion  are  often 
less  severe  than  in  uncomplicated  cases,  apparently  because  a 
certain  amount  of  the  applied  force  is  expended  in  producing 
the  fracture. 

§  803.  Symptoms. — The  symptoms  of  concussion  may  be  de- 
scribed under  four  stages:  (a)  The  stage  of  collapse;  (h)  the 
stage  of  rallying  or  of  voTniting ;  (c)  the  stage  of  reaction ; 
(cT)  the  stage  of  gradual  convalescence  (Hutchinson). 

(a)  The  Stage  of  Collapse. — The  symptoms  during  this  stage 
are  very  variable  both  in  character  and  duration.  In  the  slighter 
forms  the  patient  suffers  from  transient  confusion  of  ideas  and 
slight  giddiness.  He  may  feel  weak  and  faint,  and  be  unable 
to  maintain  the  erect  posture.     In  the  more  severe  forms  the 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  717 

symptoms  are  those  of  collapse,  with  loss  of  consciousness  ;  but 
paralysis,  such  as  occurs  in  compression  of  the  brain,  is  never 
present.  The  patient  is  semi-conscious  or  insensible,  most 
reflex  actions  are  abolished,  the  skin  is  cold  and  pallid,  the 
respirations  superficial  and  shallow,  the  pulse  feeble  or  imper- 
ceptible at  the  wrist,  whilst  the  pupils  may  either  be  con- 
tracted, dilated,  or  unequal. 

(6)  The  Stage  of  Rallying  or  of  Vomiting. — After  a  period 
varying  from  a  few  minutes  even  up  to  days,  according  to  the 
severity  of  the  attack,  the  patient  usually  begins  to  show  signs  of 
rallying.  This  stage  is  often  ushered  in  by  vomiting,  or  very 
occasionally  by  an  epileptiform  attack;  the  pulse  improves  in 
strength,  the  respirations  become  less  shallow  and  more  per- 
ceptible, the  body  becomes  warmer,  reflex  actions  can  be  excited, 
and  the  patient  gives  evidence  of  returning  sensibility,  while  he 
may  exhibit  signs  of  mental  distress. 

(c)  The  Stage  of  Reaction. — The  symptoms  of  the  stage  of 
rallying  are  succeeded  by  those  of  reaction.  In  this  stage  the 
phenomena  of  febrile  reaction  manifest  themselves  by  the  usual 
symptoms,  hot  and  dry  skin,  quick  and  hard  pulse,  and  scanty 
urine;  while  the  patient  is  drowsy,  yet  quite  conscious  when 
roused  by  a  question  addressed  to  him.  In  some  cases  these 
symptoms  gradually  develop  into  those  of  compression  and  the 
patient  dies  comatose,  while  in  other  cases  the  symptoms  of 
reaction  give  place  to  those  of  inflammation  of  the  brain.  This 
stage  may  continue  from  three  to  twelve  days  in  cases  which 
recover. 

(d)  The  Stage  of  Convalescence. — Reaction  is  followed  by  a 
progressive  subsidence  of  the  symptoms,  and  either  by  a  gradual 
restoration  of  the  patient  to  health,  or  the  establishment  of  one 
or  other  of  several  chronic  affections  of  the  nervous  system. 

Cerebral  Irritation. — In  another  form  of  nervous  disturbance 
following  injuries  of  the  head,  and  described  by  Erichsen  under 
the  name  of  cerebral  irritation,  the  phenomena  of  cerebral  ex- 
citement are  mixed  with  those  of  loss  of  function.  The  patient 
assumes  a  peculiar  attitude ;  he  lies  with  the  body  bent  for- 
wards, the  knees  drawn  up  on  the  abdomen,  the  legs  bent  on 
the  thighs,  the  forearms  flexed  on  the  arms,  and  the  hands 
drawn.     The   patient  is  restless,  and   frequently  changes  his 


718  DIFFUSED   DISEASES   OF  THE   ENCEPHALON. 

position,  but  never  stretches  himself  out  nor  assumes  the  supine 
posture  (Erichsen).  The  eyelids  are  firmly  closed,  the  pupils 
are  contracted,  the  surface  of  the  body  is  pale  and  cold,  and  the 
pulse  is'small,  feeble,  and  slow,  being  seldom  above  70  beats  per 
minute.     The  sphincters  remain,  as  a  rule,  unaffected. 

The  patient  is  indifferent  to  everything  around  him,  and  is 
only  partially  conscious.  He  may,  however,  be  roused  when 
addressed  in  a  loud  voice,  and  then  looks  up,  mutters  indis- 
tinctly, or  frowns  and  turns  hastily  away.  His  sleep  is  not 
stertorous. 

After  a  period  of  from  one  to  three  weeks,  the  pulse 
improves,  the  body  becomes  warmer,  the  flexed  attitude  is 
abandoned,  and  the  mental  irritability  gives  place  to  mental 
feebleness  and  torpidity. 

§  804.  Course,  Duration,  and  Terminations. — The  mildest 
cases  of  concussion  usually  make  a  speedy  recovery,  although  the 
patient  may  suffer  for  many  days  from  confusion  of  thought,  list- 
lessness,  and  indisposition  for  mental  exertion.  In  the  severest 
cases  rapid  death  may  occur.  Between  these  extremes  every 
intermediate  degree  in  the  severity  of  the  symptoms  is  ob- 
served. In  some  cases  the  patient  may  never  rally,  but  die  after  a 
more  or  less  prolonged  stage  of  collapse.  In  other  cases  the  patient 
rallies,  but  the  symptoms  of  reaction  are  excessive,  and  followed 
either  by  those  of  compression  or  of  encephalitis.  But  even  when 
the  period  of  reaction  is  safely  passed,  serious  consequences 
may  be  observed  during  and  subsequent  to  the  period  of  con- 
valescence. In  some  cases  complete  recovery  may  apparently 
take  place,  and  the  patient  resumes  his  ordinary  avocations; 
but  he  remains  excitable,  and  gives  way  to  uncontrollable  bursts 
of  passion.  He  complains  of  persistent  headaches,  his  mental 
powers  are  impaired,  his  speech  may  be  indistinct  and  stutter- 
ing, while  vision,  smelling,  and  hearing  may  be  permanently 
impaired.  The  severity  of  the  remote  consequences  of  concussion 
do  not  always  bear  a  direct  ratio  to  the  severity  of  the  symptoms 
of  the  first  stage  of  concussion,  apparently  trivial  cases  being 
sometimes  followed  by  serious  consequences. 

In  cerebral  irritation  recovery  is  slow,  but  may  ultimately  be 
perfect,  although  remote  consequences  are  not  unfrequently 
manifested. 


DIFFUSED  DISEASES   OF  THE   ENCEPHALON.  719 

§  805.  Morbid  Anatomy. — In  most  cases  of  death  from  con- 
cussion the  autopsy  reveals  actual  structural  changes  in  the 
brain,  consisting  of  superficial  lacerations,  or  of  minute 
hsemorrhagic  extravasations,  either  studded  on  the  surface  of 
the  brain  or  in  its  substance,  and  occasionally  of  diffused 
ecchymosis  of  the  pia  mater  (Hutchinson).  The  most  common 
sites  of  these  superficial  hsemorrhagic  extravasations  are  oppo- 
site bony  ridges,  and  at  projecting  parts  of  the  brain.  In  some 
cases  no  structural  lesions  of  any  kind  have  been  discovered.  It 
is  probable  that  in  the  majority  of  the  cases  which  recover  no 
structural  changes  which  could  be  recognised  even  by  micro- 
scopical examination  are  produced.  It  is  much  more  likely 
that  the  essential  structural  alterations  in  concussion  consist 
of  a  molecular  disturbance  of  the  substance  of  the  cerebro- 
spinal centres. 

§  806.  Morbid  Physiology. — Various  hypotheses  have  from 
time  to  time  been  advanced  to  account  for  the  phenomena  of 
concussion.  Nothnagel  thinks  that  the  strong  irritation  of  the 
sensory  nerves  produced  by  the  injury  causes  contraction  of  the 
vessels  of  the  brain,  which  in  its  turn  produces  anaemia  and  loss 
of  function  of  the  cortex,  Fischer,  on  the  other  hand,  attributes 
the  phenomena  with  more  justice  to  vascular  paralysis;  but  if 
the  shock  of  the  blow  is  sufiicient  to  paralyse  the  vaso-motor 
centres,  what  is  to  prevent  it  from  paralysing  a  more  extended 
portion  of  the  nervous  system  ?  By  far  the  readiest  way  of  ac- 
counting for  the  loss  of  function  of  the  cortex  is  to  assume 
that  the  injury  has  produced  a  molecular  disturbance  of  the 
protoplasm  of  the  tissues  of  the  brain,  which  is  accompanied 
by  an  impairment  or  abolition  of  their  functions. 

§  807.  Diagnosis. — Concussion  may  be  distinguished  from 
most  other  affections  by  the  presence  of  the  symptoms  already 
described  directly  following  a  distinct  injury.  It  is  most  likely 
to  be  mistaken  for  compression  of  the  brain.  It  may  be  dis- 
tinguished from  compression  by  the  absence  of  any  obvious  cause 
of  pressure  on  the  brain,  of  paralysis,  and  of  stertorous  breathing. 
In  compression  from  haemorrhage  a  short  interval  elapses  before 
the  symptoms  are  developed,  and  they  gradually  become  more 


720  DIFFUSED   DISEASES   OF  THE   ENCEPHALON. 

profouud,  while  in  concussion  they  immediately  follow  the  injury, 
and  usually  undergo  progressive  improvement.  In  compression 
the  pulse  is  slow  and  full,  while  in  concussion  it  is  frequent 
and  feeble. 

§  808.  Prognosis. — The  prognosis  of  concussion  is  always 
grave,  even  in  apparently  trivial  cases,  inasmuch  as  they  may 
be  followed  by  serious  remote  consequences.  The  prognosis  is 
also  more  grave  in  those  who  inherit  a  neuropathic  disposition, 
or  have  led  dissipated  lives. 

§  809.  Treatment. — The  treatment  of  concussion  consists  of 
absolute  and  prolonged  rest.  One  of  the  most  important  rules 
of  treatment  is  to  abstain  from  giving  stimulants,  except  in  un- 
usually severe  cases,  during  the  stage  of  collapse.  The  patient 
in  this  stage  should  be  surrounded  by  warm  blankets,  while 
hot  bottles  may  be  applied  to  the  feet.  Absolute  rest  in  a 
darkened  room  should  be  enjoined  until  the  stage  of  reaction 
is  passed,  while  the  diet  should  be  plain  and  unstimulating, 
consisting  mainly  of  milk.  During  the  stage  of  reaction  a 
moderate  purgative  may  be  given,  and  ice  should  be  applied 
to  the  head  at  an  early  period,  if  agreeable  to  the  patient. 
Even  in  slight  cases  prolonged  rest  should  be  insisted  upon  in 
order  to  prevent,  if  possible,  the  development  of  the  remote 
consequences  of  concussion. 

§  810.  Contusion  of  the  Brain. 

Whenever  the  skull  undergoes  a  sudden  change  of  form  as 
the  result  of  external  injury,  the  substance  of  the  brain  may 
be  contused  or  lacerated.  The  contusion  may  be  situated 
immediately  beneath  the  portion  of  the  skull  where  the  injury 
was  inflicted,  or  on  the  opposite  side  of  the  brain  as  the  result 
of  contre  coup,  or  both  these  places  may  be  simultaneously 
affected. 

The  morbid  appearances  presented  in  contusion  of  the  brain 
consist  of  capillary  hgemorrhagic  extravasations,  which  are 
usually  limited  to  the  cortex  of  the  brain,  but  may  sometimes 
extend  into  its  substance.  When  the  injury  is  limited  to  a 
small  portion  of  the  brain,  the  extravasations  may  be  so  closely 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  721 

aggregated  that  the  part  affected  may  present  the  appearance 
of  a  hsemorrhagic  infarction.  At  other  times  the  extravasations 
are  more  diffused.  The  brain  is  liable  to  be  lacerated  by  loose 
splinters,  or  a  depression  of  the  bones ;  and  when  there  is 
fracture  of  the  skull,  large  portions  of  the  brain  may  be  dis- 
organised. 

The  symptoms  of  contusion  are  always  complicated  by  those 
of  concussion  and  of  compression.  The  diagnosis  of  contusion 
must  be  made,  in  the  absence  of  the  signs  of  a  fracture  of  the 
skull,  from  the  presence  of  symptoms  indicative  of  a  local  lesion, 
as  monospasms  and  monoplegia,  in  addition  to  the  symptoms 
caused  by  a  general  injury  to  the  brain. 

The  prognosis  of  these  cases  is  usually  serious,  but  not  neces- 
sarily fatal. 

§  811.  Compression  of  the  Brain. 

Compression  of  the  brain  may  occur  after  injuries  from  the 
pressure  of  a  fractured  portion  of  the  bones  of  the  skull,  the 
presence  of  extravasated  blood,  pus  formed  within  the  skull,  or 
of  a  foreign  body  lodged  there. 

The  patient  becomes  unconscious,  the  breathing  is  slow,  deep, 
and  stertorous,  while  the  cheeks  are  puffed  out  during  respira- 
tion. The  surface  of  the  body  is  cool  at  first,  but  soon  becomes 
hot  and  bathed  in  perspiration.  The  pupils  are  dilated  or  un- 
equal, the  pulse  is  slow  and  full,  the  faeces  pass  involuntarily, 
and  there  is  retention  of  urine.  This  condition  of  stupor  some- 
times alternates  with  paroxysms  of  delirium,  while  local  spasms 
or  paralyses  are  sometimes  observed,  but  it  is  probable  that  in 
these  cases  the  motor  area  of  the  cortex  has  been  lacerated  or 
contused. 

For  further  information  with  regard  to  contusion  and  com- 
pression of  the  brain  the  reader  is  referred  to  surgical  works. 


uu 


722 


CHAPTER    XIII. 


II.  DIFFUSED  DISEASES  OF  THE  ENCEPHALON  (Continued). 


(IV.)    ENCEPHALITIS. 

Encephalitis  consists  of  primary  inflammation  of  the  substance 
of  the  brain  followed  by  softening  and  in  certain  instances  by 
abscess.  Two  kinds  are  usually  described,  namely,  (1)  diffused 
or  genercd  ;  and  (2)  particd  or  local  encephalitis. 

§  812.  Etiology. — The  most  frequent  cause  of  acute  inflam- 
mation and  abscess  of  the  brain  is  recent  injury.  Primary 
traumatic  encephalitis  is  most  acute  when  the  atmospheric  air 
is  allowed  to  gain  access  to  the  wound,  and  in  such  cases  it  is 
associated  with  meningitis  ;  but  encephalitis  may  result  from 
contusions  of  the  brain  in  the  absence  of  any  perforating 
wound  of  the  skull,  and  such  cases  often  terminate  in  chronic 
abscess  of  the  brain. 

Affections  of  the  bones  of  the  skull,  such  as  caries  and 
accumulations  of  pus  in  the  petrous  portion  of  the  temporal 
bone,  may  cause  encephalitis,  either  by  an  inward  extension  of 
the  inflammatory  process  or  by  infection.  The  presence  of 
tumours  gives  rise  to  inflammation  of  the  surrounding  brain 
tissue,  and  a  certain  amount  of  encephalitis  is  always  met  with 
in  cases  of  infantile  apoplexy. 

Multiple  cerebral  abscesses  occur  in  connection  with  acute 
febrile  affections,  more  especially  typhoid  fever,  and  are 
generally  occasioned  by  metastasis  from  other  organs.  In 
scarlet  fever  abscesses  of  the  brain  result  from  affections  of  the 
internal  ear  and  petrous  part  of  the  temporal  bone.  Localised 
inflammatory  processes   occur  in   the   brain   in   measles,   and 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON,  723 

Westphal  found  them  also  in  the  spinal  cord  in  variola.  Cir- 
cumscribed affections  of  the  brain  are  met  with  in  carbonic- 
oxide  poisoning,  but  these  appear  to  be  of  necrotic  origin 
(Huguenin).  Ulcerative  endocarditis  may  give  rise  to  abscess 
of  the  brain  by  multiple  embolism  of  the  cerebral  vessels. 
Chronic  putrid  bronchitis  and  bronchiectasis  are  especially 
liable  to  produce  secondary  abscess  in  the  brain,  and  unhealthy 
suppurations  in  other  parts  of  the  body  may  have  the  same 
result. 

JSncapsulated  abscesses  are  produced  for  the  most  part  by 
the  same  causes  that  give  rise  to  acute  abscess.  Lebert  found 
that  injury  was  the  cause  of  eocapsulated  abscess  in  about  a 
sixth  of  his  cases,  Schott  in  thirteen  out  of  forty,  Meyer  in 
twenty-one  out  of  eighty-six,  and  Huguenin  in  one  case  out  of 
every  four.  The  encapsulated  abscess  is  frequently  situated  at 
a  point  in  the  brain  opposite  to  that  where  the  injury  was 
received. 

Abscesses  of  the  brain  secondary  to  affections  of  the  ear  are 
situated  most  frequently  in  the  hemispheres,  less  frequently  in 
the  cerebellum,  and  in  very  rare  cases  in  the  pons ;  the  right 
hemisphere  is  oftener  the  seat  of  the  abscess  than  the  left. 
According  to  Mr.  Toynbee,  the  inflammation  of  each  portion  of 
the  organ  of  hearing  is  transmitted  to  a  particular  region  of 
the  brain.  Affections  of  the  cavity  of  the  tympanum  cause 
abscess  of  the  cerebrum ;  those  of  the  meatus  auditorius 
externus  induce  disease  of  the  lateral  sinus  and  of  the  cere- 
bellum; while  affections  of  the  labyrinth  cause  disease  of  the 
medulla  oblonofata.  He  also  states  that  when  the  mastoid  cells 
are  diseased  in  early  life  the  cerebrum  is  the  part  most  likely 
to  suffer;  while  in  later  periods  of  life,  the  cerebellum  is 
generally  affected. 

Inflammation  is  transmitted  in  a  small  number  of  cases  to 
the  brain  from  the  nose,  Antrum  of  Highmore,  and  orbit.  Polypi 
in  the  nose  and  frontal  sinuses  may  cause  absorption  of  the 
frontal  bone,  inflammation  of  the  dura  mater,  and  an  abscess  in 
the  anterior  lobe  of  the  brain.  Gull  mentions  two  cases  where 
the  inflammation  was  transmitted  from  the  nasal  to  the  cerebral 
cavity.  Caries  of  the  other  bones  of  the  skull,  especially  that 
due  to  syphilis,  also  gives  rise  to  cerebral  abscess. 


724  DIFFUSED   DISEASES  OF   THE   ENCEPHALON. 

Suppuration  occurs  around  tumours,  but  it  is  less  frequent 
than  red  softening. 

The  male  is  more  liable  to  abscess  of  the  brain  than  the  ' 
female  sex,  probably  from  the  former  being  more  exposed  to 
injuries,  and  for  a  similar  reason  the  greatest  number  of  cases 
occur   between    the    twentieth    and   thirtieth   years    of   age. 
Cerebral  abscess  is  very  rare  after  the  sixtieth  year  of  age. 

§  813.  Symptoms. — No  general  description  of  acute  encepha- 
litis can  be  given  which  will  apply  to  all  cases.  Injuries  to  the 
head  are  often  accompanied  by  contusions  of  the  brain,  which 
may  be  followed  by  acute  localised  encephalitis.  Superficial 
lesions,  provided  they  be  exposed  to  the  air,  lead  to  red  soften- 
ing, with  consecutive  acute  diffused  suppuration  of  the  brain  ; 
while  deep  contusions  may  be  followed  by  red  softening  and 
suppuration,  which  tend  to  develop  into  chronic  encapsulated 
abscesses.  The  stage  of  encephalitis  without  suppuration  is 
generally  transitory,  and  its  symptoms  are  difficult  to  recognise, 
more  especially  as  the  symptoms  often  commence  during  the 
period  of  unconsciousness  caused  by  the  original  contusion. 

1.    Diffused  or  General  Encephalitis. 

When  the  contusion  is  superficial  encephalitis  is  complicated 
by  meningitis,  and  it  is  impossible  to  distinguish  the  symptoms 
which  belong  to  each  affection. 

When  diffuse  meningitis  supervenes  after  injury,  local  symp- 
toms such  as  isolated  spasm,  paralysis,  or  aphasia  may  occur, 
and  a  distinct  spot  of  red  softening  be  found  at  the  autopsy  to 
account  for  them.  But  when  the  lesion  of  the  cortex  is  situated 
beyond  the  motor  area,  psychical  symptoms  of  a  very  general 
character  are  alone  produced. 

2.  Partial  or  Local  Encephalitis. 
An  encephalitic  focus  in  the  substance  of  the  brain  may  also 
give  rise  to  localised  motor  or  sensory  symptoms  when  the 
pyramidal  tract  or  the  sensory  peduncular  fibres  are  affected  ; 
but  a  focus  of  acute  inflammation  may  exist  in  the  frontal, 
temporal,  or  occipital  lobes  without  giving  rise  to  any  symp- 
toms indicative  of  localised  disease.      An  acute  encephalitis 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  725 

following  an  injury  of  the  head  without  fracture  may  conse- 
quently run  its  course  without  our  having  a  suspicion  of  its 
existence. 

When  a  contusion  in  the  interior  of  the  brain  has  taken 
place,  the  patient  first  suffers  from  the  usual  symptoms  of  con- 
cussion, and  it  is  only  when  these  have  disappeared  that  the 
symptoms  of  local  encephalitis  can  be  recognised.  The  patient 
lies  in  a  semi-conscious  condition,  and  when  roused  complains 
of  headache  and  dizziness,  and  staggers  on  attempting  to 
walk.  The  pupils  are  variable  in  size,  generally  equal  and 
reacting  slowly  to  light.  The  countenance  is  usually  suffused, 
but  at  times  turns  pale,  and  the  pulse,  which  was  frequent  and 
irregular  during  the  stage  of  concussion,  sinks  to  60  or  70  beats, 
and  the  thermometer  may  reveal  the  existence  of  fever  of 
remittent  type. 

The  symptoms  are  at  times  so  insignificant  that  after  a  few 
days  the  patient  feels  quite  well,  or  indefinite  symptoms  may 
continue  for  two  or  three  weeks. 

Suddenly,  however,  these  symptoms  become  more  intense, 
the  fever  increases,  but  is  still  of  irregular  type,  the  dizziness 
and  headache  become  more  marked,  vomiting  is  not  un- 
frequent,  the  pupils  are  dilated  and  fixed,  the  pulse  is  slow, 
the  patient  falls  into  a  condition  of  sopor,  which  may  be 
accompanied  by  delirium,  or  may  pass  directly  into  complete 
unconsciousness. 

As  the  case  progresses  graver  symptoms  appear -in  rolling  of 
the  eyes,  transitory  divergence,  sudden  permanent  paralysis  of 
the  abducens,  motor  oculi,  or  facial  nerve,  and  in  a  few  cases 
hemiparesis  or  hemiplegia.  Convulsive  symptoms  are  some- 
times present,  usually  consisting  of  twitchings  of  both  hands, 
or  there  may  be  clonic  convulsions  of  the  limbs.  In  some  cases 
a  general  convulsion  occurs  which  varies  greatly  in  duration 
and  intensity  in  different  cases.  The  sopor  now  grows  deeper, 
the  previously  slow  pulse  becomes  quick  and  irregular,  and  death 
takes  place  in  coma.  The  course  of  the  temperature  varies, 
but  a  continuous  elevation  until  death  is  exceptional. 

The  duration  of  the  symptoms  is  variable.  Beck  found  an 
abscess  of  the  brain  on  the  fifth  day  after  an  injury  of  the  head, 
and  Huguenin  on  the  twelfth  day.      When  the   air  obtains 


726  DIFFUSED   DISEASES   OF   THE   ENCEPHALON. 

access   to   a   peripheral   cerebral   contusion,    and   suppuration 
occurs,  death  supervenes  more  rapidly. 

The  dangerous  symptoms  of  traumatic  encephalitis  may 
occasionally  disappear,  and  the  patient  be  restored  to  compa- 
rative health.  The  inflammatory  focus  may  be  transformed 
into  a  relatively  innocuous  condition,  but  in  many  cases  chronic 
changes  of  a  diffused  character  are  occasioned  which  give  rise 
to  more  or  less  permanent  symptoms.  The  more  usual  groups 
of  symptoms  caused  by  these  changes  are  the  following: — 

(i.)  Chronic  psychosis  in  the  form  of  irritable  melancholia, 
followed  by  recovery  (Huguenin). 

(ii.)  A  psychosis  characterised  by  severe  headache,  dizziness, 
anxiety,  and  hallucinations ;  the  intellectual  faculties  are  im- 
'  paired,  and  there  are  intercurrent  periods  of  excitement  and 
constant  illusions  of  the  senses.  A  few  cases  recover,  but  in 
the  majority  this  condition  continues  for  years,  and  at  last  ends 
in  complete  imbecility. 

(iii.)  Symptoms  resembling  those  of  dementia  paralytica 
supervene  at  a  variable  period  of  weeks  or  years  after  the 
injury.  The  development  of  the  disease  after  an  injury  is 
slow,  and  the  course  is  protracted. 

(iv.)  A  psychical  vulnerability  frequently  remains,  which  is 
apt  to  develop  into  some  form  of  insanity  from  some  slight 
exciting  cause.  In  these  cases  the  disposition  of  the  patient  is 
generally  changed,  there  is  great  mental  irritability  and  hyper- 
sesthesia  along  with  diminution  of  the  power  of  sustained 
thought,  and  insanity  may  supervene  many  years  after  the 
injury. 

(v.)  Epilepsy  is  a  frequent  result  of  the  chronic  changes  in 
the  skull  that  follow  an  injury.  Old  depressions  of  the  skull 
are  often  associated  with  epilepsy. 

(vi.)  Tumours  of  the  brain  have  been  known  to  follow  injury 
(Griesinger,  Recklinghausen). 

(vii.)  Diabetes  has  supervened  immediately  after  a  fall  on 
the  back  of  the  head. 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  727 

a.  Acute  Encephalitis,  complicating  affections  of  the  petrous 
portion  of  the  Temporal  Bone,  and  of  other  Bones  of  the 
Skull. 

§  814.  Symptoms.  —  The  symptoms  caused  by  the  acute 
encephalitis,  which  accompanies  caries  of  the  petrous  bone,  are 
often  obscured  by  co-existing  meningitis  and  thrombosis  of  the 
sinuses.  An  abscess  in  the  temporal  lobe  may  attain  a  con- 
siderable size,  and  cause  general  symptoms  of  compression 
before  giving  rise  to  symptoms  of  local  disease,  inasmuch  as 
this  lobe  does  not  contain  any  direct  sensory  or  motor  con- 
ducting tracts.  Acute  abscesses  of  the  temporal  lobe  are  con- 
sequently seldom  recognised  during  life.  Otorrhcea  may  occur 
at  all  ages,  although  it  is  most  common  in  scrofulous  children 
especially  after  attacks  of  scarlet  fever;  while  a  purulent  dis- 
charge from  the  ear  has  occasionally  been  observed  immediately 
after  birth,  the  affection  being  then  apparently  congenital. 
Acute  cerebral  abscess  from  otorrhoea  runs  a  very  rapid  course, 
its  duration  being  from  four  to  twenty  or  more  days. 

The  symptoms  are  those  which  usually  result  from  a  sudden 
and  progressive  compression  of  the  brain,  but  general  convul- 
sions may  precede  the  development  of  complete  coma.  Fever, 
of  variable  type,  is  usually  present,  the  pulse  is  slow,  and  the 
pupils  contracted  and  sluggish. 

Severe  headache  is  usually  the  first  symptom  of  the  affection, 
but  it  is  soon  followed  by  vomiting,  ringing  in  the  ears,  con- 
fusion of  ideas  and  loss  of  memory,  and  mild  delirium.  As 
the  disease  advances  the  headache  becomes  more  and  more 
intense,  the  patient  is  delirious  and  at  times  unconscious,  epilep- 
tiform convulsions  supervene,  and  the  case  soon  terminates 
fatally  amidst  profound  coma. 

In  some  cases  the  general  symptoms  just  described  are  com- 
plicated by  those  of  a  localised  disease.  In  such  cases  the 
abscess  increases  rapidly  in  size,  and  involves  the  base  of  the 
lenticular  nucleus,  compressing  the  fibres  of  the  internal  cap- 
sule, and  thus  causing  an  incomplete  hemiplegia  with  various 
sensory  disturbances.  It  may  also  compress  the  cerebral 
peduncle,  and  thus  cause  paralysis  of  the  oculo-motor  nerve, 
while  paralysis  of  the  facial  nerve  has  occasionally  been  observed. 


728  DIFFUSED  DISEASES   OF   THE   ENCEPHALON. 

Cases  of  this  kind  pursue  a  rapid  course,  and  terminate  fatally 
in  a  short  time, 

A  few  cases  are  associated  with  acute  meningitis  or  throm- 
bosis of  the  lateral  sinus. 

h.   Acute  Pycemic  Encephalitis. 

The  initial  symptoms  of  this  affection  are  somewhat  variable 
and  often  masked.  There  are  frequently  rigors,  but  these  are 
symptomatic  of  the  general  disease.  The  brain  affection  is 
ushered  in  by  severe  headache,  usually  frontal,  dizziness,  mental 
disturbance,  slight  somnolence,  occasionally  delirium,  unilateral 
convulsions  in  an  arm  or  leg  or  both,  formication  and  other 
forms  of  dyssesthesia,  or  a  slight  diminution  of  sensibility. 

The  disease  usually  makes  rapid  progress,  and  graver  symp- 
toms soon  supervene.  There  is  intense  headache,  dizziness  is 
so  great  that  the  patient  cannot  stand  or  walk,  the  mind  is 
confused,  and  delirium  supervenes,  but  soon  gives  place  to  pro- 
found coma. 

The  local  symptoms  consist  of  convulsive  movements  of  the 
eyes,  face,  or  of  one  of  the  limbs,  which  may  end  in  unilateral 
or  general  convulsions.  There  may  be  at  times  a  considerable 
elevation  of  temperature,  but  the  intensity  of  the  febrile  symp- 
toms is  variable. 

c.  Encephalitis  around  pre-existing  lesions  in  the  brain,  such 
as  tumours,  necrotic  softenings,  and  extravasations  of 
blood. 

(a)  Cerebral  Hcemorrhage. — Within  a  variable  period  after 
a  cerebral  hsemorrhage,  a  zone  of  red  softening  is  found  around 
the  primary  focus,  in  which  an  abundance  of  migrated  corpuscles 
may  be  observed.  Suppuration,  however,  is  rare,  if  it  ever  occur. 
Beyond  the  area  of  red  softening  a  second  zone  may  be  observed 
in  which  the  tissues  of  the  brain  are  unusually  dense,  owing  to 
a  great  increase  of  the  neuroglia  corpuscles,  while  the  tissues 
surrounding  this  zone  may  be  extensively  cedematous.  Secon- 
dary hsemorrhages  may  occur  in  the  circumference  of  the  pri- 
mary apoplectic  focus. 

(6)  Necrotic  Softening  from  Thrombosis  and  Embolism.. — 
The  primary  focus  consists  of  a  hsemorrhagic  infarct,  which  is 


DIFFUSED  DISEASES  OF  THE  ENCEPHALON.  729 

followed  by  inflammation  of  the  surrounding  tissues.  The  in- 
farct is  thus  surrounded  by  a  red  areola,  studded  with  capillar}^ 
extravasations,  which  in  its  turn  is  surrounded  by  a  yellowish 
zone,  and  the  latter  by  a  more  or  less  extensive  zone  of 
oedematous  tissue. 

The  inflammatory  process  around  the  focus,  as  a  rule, 
gradually  ceases,  the  central  portion  of  the  part  affected  be- 
coming transformed  into  a  cyst  containing  a  clear  serous  fluid, 
and  sometimes  connective  tissue  septa,  or  into  a  number  of 
small  lacunae  containing  a  cloudy  serum. 

(c)  Tumour. — The  secondary  softening  caused  by  tumours 
of  the  brain  is  usually  most  marked  around  tumours  like  the 
carcinomata,  which  grow  quickly. 

The  processes  around  tumours  may  be  divided  into  several 
varieties : — 

(i.)  Simple  softening  and  oedema  of  the  surrounding  tissues, 
caused  by  retardation  of  the  circulation,  and  probably  by 
thrombosis. 

(ii.)  Capillary  and  larger  extravasations,  probably  due  to 
fatty  degeneration  of  the  walls  of  the  vessels. 

(iii.)  Genuine  encephalitic  red  softening,  accompanied  by 
rupture  of  minute  vessels,  migration  of  cells,  and  extensive 
oedema  of  the  brain. 

(iv.)  Suppuration  around  tumours  is  occasionally  observed. 

§  815.  Symptoms, 
(a)  Cerebral  Hcemorrhage. — Some  of  the  symptoms  which 
follow  a  cerebral  hsemorrhage  must  be  ascribed  to  consecutive 
encephalitis.  The  patient  may  have  made  a  good  recovery 
from  the  early  symptoms  of  an  apoplectic  attack,  but  several 
days  afterwards  there  is  a  fresh  elevation  of  temperature,  and 
the  pulse  becomes  hard  and  frequent.  The  patient  complains  of 
headache,  there  may  be  slight  wandering  and  confusion  of  ideas, 
and  he  may  fall  into  a  somnolent  condition.  The  general  are 
soon  followed  by  local  symptoms,  consisting  usually  of  the  well- 
known  secondary  contractures.  Some  patients  may  manifest 
only  slight  tremor  of  the  paralysed  limbs  ;  in  others  the  flexors 
are  in  a  state  of  contracture,  while  in  a  third  series  of  cases 


730  DIFFUSED   DISEASES   OF  THE  ENCEPHALON. 

these  conditions  alternate.  The  temperature  of  the  paralysed 
side  is  often  considerably  elevated,  and  anomalies  in  the  secre- 
tion of  sweat  are  observed.  The  somnolence  may  now  increase 
to  a  deep  sopor,  which  lasts  several  days,  and  may  pass  into 
profound  and  fatal  coma. 

In  those  cases  that  recover  symptoms  frequently  persist 
which  show  that  a  chronic  encephalitis  is  established.  There 
is  persistent  headache,  frequent  attacks  of  dizziness,  and  the 
patient  is  subject  to  congestive  attacks,  each  of  which  may 
cause  new  convulsions  in  the  paralysed  limbs.  The  paralysed 
limbs  are  generally  subject  to  pains  of  variable  character, 
situated  either  in  the  joints,  bones,  skin,  or  muscles.  Secondary 
encephalitis  is  also  the  chief  cause  of  the  atrophy  of  the  brain 
observed  in  many  of  these  patients,  and  which  is  always 
associated  with  profound  psychical  disturbances. 

(b)  Thrombosis  and  Embolism. — In  senile  encephalomalacia 
the  symptoms  of  secondary  encephalitis  are  caused  by  an  in- 
crease of  the  intracranial  pressure  on  the  one  hand,  and  irrita- 
tion of  the  surrounding  parts  on  the  other.  The  symptoms  of 
inflammatory  reaction  are  slight ;  and  when  a  certain  degree  of 
senile  atrophy  of  the  brain  had  existed  previous  to  the  occur- 
rence of  the  attack,  the  mental  functions  become  progressively 
abolished  without  being  preceded  by  symptoms  of  active  irrita- 
tion or  by  those  indicative  of  a  gradual  compression  of  the 
brain.  It  frequently  happens  that,  after  the  formation  of  a 
diseased  focus  in  the  brain,  a  febrile  condition,  attended  by  a 
drowsy  delirium  or  somnolence,  continues  for  some  time,  and 
either  develops  into  permanent  imbecility  or  gives  place  to 
partial  restoration  of  the  mental  faculties.  When  the  last  result 
occurs  the  mental  condition  of  the  patient  is  characterised  by 
weakness  of  memory,  irregular  and  causeless  outbursts  of  temper, 
and  a  disposition  to  the  shedding  of  tears,  and  other  emotional 
displays.  The  patient  is  liable  to  congestive  attacks  which 
occasion  temporary  unconsciousness,  and  during  these  new  foci 
of  softening  may  be  developed  in  the  brain.  Convulsions  of  the 
partially  paralysed  limbs  may  occur,  and  in  rare  cases  general 
convulsions. 

(c)  Tumour. — A  great  many  of  the  symptoms  observed  in 
tumours  of    the   brain    must   be   ascribed   to   the   secondary 


DIFFUSED  DISEASES   OF  THE   ENCEPHALON.  731 

encephalitis  in  the  surrounding  tissue.  The  symptoms  which 
may  with  probability  be  ascribed  to  encephalitis  during  the 
growth  of  a  cerebral  tumour  are  the  occurrence  of  sudden  apo- 
plectiform attacks,  the  rapid  conversion  of  slight  muscular 
weakness  into  complete  paralysis,  partial  convulsions  followed 
by  paralysis,  general  convulsions,  and  the  gradual  development 
of  coma.  When  coma  is  suddenly  developed  in  the  course  of  the 
growth  of  a  cerebral  tumour,  it  is  more  likely  to  be  caused  by 
hgemorrhage,  or  sudden  oedema,  than  by  encephalitis.  Every 
secondary  encephalitis,  however  slight,  produces  violent  head- 
ache, although  such  attacks  may  be  due  to  a  congestive  swelling 
of  the  tumour  itself  Encephalitis  around  a  tumour  which 
involves  the  sensitive  fibres  of  the  corona  radiata  is  liable  to 
cause  disturbances  of  sensation  in  the  opposite  side  of  the  body. 

d.  Chronic  Abscess  of  the  Brain. 

Chronic  abscess  of  the  brain  may  be  subdivided  into  (i.) 
primary  and  (ii.)  secondary  chronic  abscess. 

(i.)  Primary  chronic  abscess  is  usually  caused  by  some 
injury  of  the  brain.  All  the  symptoms,  or  nearly  all,  may  dis- 
appear soon  after  the  injury,  and  a  period  relatively  free  from 
symptoms  may  follow,  forming  the  latent  stage  of  chronic 
abscess.  The  average  duration  of  the  latent  stage  is,  according 
to  Lebert,  from  one  to  two  months,  but  the  period  may  vary  in 
individual  cases  from  a  few  days  to  years.  When  once  a  chronic 
abscess  is  formed,  the  symptoms  caused  by  it  are  more  or  less 
similar  to  those  of  cerebral  tumour;  and  when  the  former  is 
situated  in  the  motor  areas  of  the  cortex  and  centrum  ovale, 
or  injure  the  sensory  peduncular  fibres,  the  symptoms  of  a 
local  lesion  are  present  from  the  beginning.  The  symptoms 
may  be  divided  into  those  of  (1)  the  latent,  and  (2)  the  ter- 
minal stages. 

(1)  Symptoms  of  the  Latent  Period. 

(a)  In  some  cases  a  persistent  headache  subject  to  paroxysmal 
exacerbations  is  the  only  symptom  present  which  could  lead  to 
the  suspicion  of  the  existence  of  an  intracranial  affection,  and 
in  a  few  rare  cases  this  symptom  may  be  absent. 

(6)  In  other  cases  symptoms  of  a  local  disease  appear  which 


732  DIFFUSED  DISEASES   OF  THE   ENCEPHALON, 

make  it  possible  to  diagnosticate  the  locality  of  the  lesion, 
while  the  history  of  the  case  and  the  concomitant  phenomena 
may  place  the  nature  of  the  lesion  beyond  doubt.  The  local 
symptoms  caused  by  chronic  abscess  are  the  same  as  those  of 
all  other  focal  diseases. 

(c)  In  other  cases  the  symptoms  of  the  latent  stage  are 
those  of  a  moderate  degree  of  intracranial  pressure.  These 
consist  of  constant  headache,  with  paroxysmal  exacerbations 
accompanied  by  slight  febrile  disturbance,  dizziness,  nausea, 
and  occasionally  vomiting.  The  headache  may  be  limited  to  the 
spot  where  the  injury  was  received,  or  correspond  to  the  part 
of  the  brain  where  the  abscess  is  situated,  the  latter  being  often 
at  a  point  of  the  brain  exactly  opposite  the  seat  of  injury. 
Paroxysmal  exacerbations  of  the  headache  are  indicative  of 
congestion  around  the  abscess,  and  when  these  frequently  recur 
the  abscess  is  likely  to  prove  fatal  within  a  brief  space  of  time. 

{d)  In  a  fourth  series  of  cases  the  symptoms  are  indicative 
of  intermittent  pressure  on  the  brain,  with-  intervals  of  com- 
parative freedom  from  all  cerebral  symptoms.  The  patient,  in 
the  midst  of  comparative  health,  may  suddenly  complain  of 
intense  headache,  he  becomes  somnolent,  and  falls  into  a  deep 
but  transitory  coma  of  several  hours'  duration,  from  which  he 
rapidly  recovers.  Such  attacks  are  probably  due  to  sudden 
pressure  on  the  brain  from  congestion. 

(e)  The  so-called  latent  stage  is  sometimes  characterised  by 
epileptiform  convulsions,  which  may  be  regarded  during  life  as 
true  epilepsy  (Hutchinson,  Jackson).  General  convulsions  are 
rare  during  this  stage. 

(2)  Symptoms  of  the  Terminal  Period. 

When  once  the  terminal  period  begins,  abscess  of  the  brain 
generally  leads  to  death  in  a  few  days.  The  symptoms  of  this 
period  differ  widely  in  individual  cases,  and  the  following  groups 
may  be  distinguished  : — 

(a)  Terminal  cedema  of  the  brain  is  the  most  usual  mode  of 
termination  of  chronic  abscess.  In  the  majority  of  cases  the 
tissues  of  the  brain  are  compressed  to  such  an  extent  that  death 
by  coma  results  in  two  or  three  days,  while  in  a  few  cases  the 
course  of  the  symptoms  is  characterised  by  temporary  improve- 


DIFFUSED  DISEASES   OF   THE   ENCEPHALON.  733 

merits  and  aggravations,  so  that  the  fatal  issue  may  be  delayed 
for  some  time.  In  some  cases  there  may  be  a  transitory  initial 
stage  of  irritation,  characterised  by  mental  irritability,  rest- 
lessness, illusions,  violent  delirium,  and  a  slight  elevation  of 
temperature.  The  irritative  symptoms  soon  give  place  to 
those  of  depression,  the  patient  complains  of  headache,  the 
temperature  falls,  the  pulse  is  slow,  the  pupils  are  dilated  and 
react  feebly  to  light,  there  is  mental  confusion,  and  the  patient 
falls  into  a  somnolent  condition,  from  which  he  may  be  roused 
temporarily  when  pressed  by  questions ;  but  in  a  short  time 
coma  supervenes,  and  the  case  soon  terminates  fatally,  the  pulse 
becoming  small,  quick,  and  irregular  before  death. 

Chronic  abscess  in  the  region  of  distribution  of  the  posterior 
and  anterior  cerebral  arteries  may  run,  as  we  have  seen,  their 
course  without  giving  rise  to  marked  motor  or  sensory  symp- 
toms. But  even  when  the  abscess  is  situated  in  one  of  these 
regions  convulsions  are  not  always  absent  during  the  terminal 
period.  An  abscess  in  the  prag-frontal  region  may,  for  instance, 
give  rise  to  partial  convulsions,  either  limited  to  or  beginning 
in  the  face  and  extending  to  the  arm,  these  convulsions  being 
followed  by  paralysis.  General  convulsions  are  sometimes 
caused  by  abscess  situated  in  the  latent  regions  of  the  hemi- 
sphere, and  these  are  usually  followed  by  profound  coma.  The 
symptoms  of  local  disease  which  may  have  been  present  during 
the  latent  stage  of  the  abscess  are  variously  modified  in  the 
terminal  stage.  Partial  convulsions  which  may  have  been 
present  become  more  violent  and  are  soon  followed  by  para- 
lysis, or  they  may  become  transformed  into  a  series  of  epilep- 
tiform attacks  terminating  in  coma. 

(h)  Rupture  of  the  Abscess  on  the  Surface  of  the  Brain. — 
When  abscesses  make  their  way  to  the  surface  of  the  brain,  an 
acute  and  rapidly  fatal  meningitis  generally  results.  The 
symptoms  of  irritation  are  at  first  predominant,  consisting  of 
general  convulsions  and  delirium.  The  patient,  however,  soon 
becomes  unconscious,  and  dies  comatose  in  a  short  time. 

(c)  Perforation  of  the  Abscess  into  the  Ventricle. — This 
occurrence  causes  a  group  of  symptoms  which  may  be  recog- 
nised, if  the  existence  of  an  abscess  have  been  previously 
suspected.    A  sudden  cerebral  attack,  attended  by  bilateral,  but 


734  DIFFUSED   DISEASES   OF   THE  ENCEPHALON. 

more  or  less  partial  convulsions,  such  as  spasms  of  both  legs,  or 
of  the  facial  muscles  on  both  sides,  is  an  indication  of  rup- 
ture into  the  ventricles,  provided  the  patient  be  not  already  in 
an  unconscious  condition.  General  convulsions  have  sometimes 
been  observed.  Clonic  spasms  of  the  ocular  muscles  soon 
appear,  caused  probably  by  irritation  of  the  corpora  quad- 
rigemina.  The  patient  becomes  rapidly  unconscious,  hemiplegia 
and  death  in  profound  coma  take  place  generally  in  from  four 
to  twenty-four  hours  after  the  rupture  of  the  abscess. 

(d)  Abscess  of  the  cerebellum  may  terminate  suddenly  from 
arrest  of  the  respiratory  functions  produced  by  pressure  on  the 
medulla  oblongata. 

(e)  Occasionally  the  brain  is  found  in  a  condition  of  remark- 
able anaemia,  and  in  such  cases  the  immediate  cause  of  death 
is  not  evident. 

(ii.)  Secondary  Chronic  Abscess  of  the  Brain. — Secondary 
chronic  abscesses  are  generally  caused  by  affections  of  the  inner 
ear.  The  diagnosis  of  the  presence  of  chronic  abscess  of  the 
brain  is  difficult,  inasmuch  as  only  a  small  proportion  of  such 
cases  give  rise  to  characteristic  symptoms.  When  the  abscess 
is  encapsulated  it  may  remain  latent  for  a  long  period,  so  that 
no  disease  of  the  brain  is  suspected  until  the  terminal  period. 
Even  the  terminal  symptoms  present  varieties  which  tend  to 
obscure  the  diagnosis,  these  symptoms  sometimes  resembling 
those  of  diffuse  meningitis,  and  at  other  times  those  of  throm- 
bosis of  a  sinus. 

§  816.  Varieties. — The  following  varieties  of  chronic  abscess 
secondary  to  disease  of  the  ear  may  be  distinguished  : — {a) 
Chronic  abscess  with  distinct  typical  course ;  (6)  Chronic  abscess 
with  terminal  stage  alone  distinct ;  (c)  Chronic  abscess  with 
thrombosis  of  the  lateral  sinus  ;  {d)  Chronic  abscess  compli- 
cated during  the  terminal  period  by  meningitis. 

(a)  In  affections  of  the  inner  ear  abscess  may  form  in  the 
temporo-sphenoidal  lobe.  In  a  long-standing  case  of  disease 
of  the  internal  ear,  where  rigors  and  other  general  inflam- 
matory symptoms  are  associated  with  severe  pain  in  the  head, 
vomiting,  convulsions,  and  other  cerebral  symptoms,  the  forma- 


DIFFUSED   DISEASES   OF  THE  ENCEPHALON.  735 

tion  of  an  abscess  in  the  brain  may  be  suspected.  These 
symptoms  may  pass  off,  and  the  patient  enjoy  apparent 
health  for  months,  with  probably  occasional  headaches.  The 
terminal  stage  is  announced  by  intense  headache  and  dizziness 
soon  followed  by  loss  of  consciousness  and  stertorous  breathing. 
Consciousness  may  be  partially  restored  in  a  few  hours,  and 
the  patient  then  suffers  from  intense  headache  and  vomiting. 
After  a  short  time  the  patient  lapses  a  second  time  into  a  semi- 
conscious condition,  and  convulsions,  generally  unilateral,  super- 
vene. Spasm  followed  by  paralysis  of  the  ocular  muscles  is 
not  an  unfrequent  symptom,  and  when  the  abscess  is  so  large 
that  it  extends  to  the  lenticular  nucleus  and  compresses  the 
internal  capsule,  or  the  fibres  of  the  pyramidal  tract  in  the 
crusta,  a  certain  degree  of  hemiplegia  may  be  present. 

(6)  Chronic  abscess  of  the  brain  is  sometimes  observed  in 
cases  of  caries  of  the  petrous  bone,  in  which  the  terminal 
symptoms  have  not  been  preceded  by  those  indicative  of  irri- 
tation or  encephalitis. 

(c)  Chronic  abscess  of  the  brain  sometimes  precedes,  at  other 
times  succeeds  to  thrombosis  of  the  lateral  sinus.  The  chief 
initial  symptoms  are,  besides  those  of  the  ear  affection,  dizziness, 
intense  headache,  and  occasionally  transitory  delirium,  followed 
by  somnolence.  The  patient  suffers  from  frequently-repeated 
rigors  if  the  temperature  of  the  body  be  raised,  and  the  fever 
assumes  a  remittent  type.  In  the  further  progress  of  the  case 
the  symptoms  may  pursue  either  of  two  directions.  The 
symptoms  may  be  those  of  progressively  increasing  pressure 
upon  the  brain,  ending  in  coma,  or  the  general  symptoms 
indicative  of  compression  may  be  associated  with  those  of  a 
localised  disease,  provided  the  abscess  has  attained  a  sufficient 
size  to  press  upon  the  internal  capsule.  General  convulsions 
may  occur  immediately  before  death. 

(d)  Chronic  abscess  of  the  brain  may  be  complicated  during 
the  terminal  period  by  meningitis,  and  when  the  initial  stage 
of  the  former  is  latent,  the  terminal  symptoms  may  be  so  similar 
to  those  of  primary  acute  meningitis  that  the  two  affections 
cannot  be  distinguished  from  one  another  during  life. 


736  DIFFUSED  DISEASES   OF   THE   ENCEPHALON. 

§  817.  Morbid  Anatomy. — In  encephalitis  the  affected  tissue 
assumes  a  reddish  colour,  and  is  studded  by  a  number  of  capil- 
lary extravasations,  each  about  the  size  of  a  pin's  head,  these 
being  sometimes  so  numerous  that  the  affected  part  presents 
the  appearance  of  a  hsemorrhagic  infarct.  These  capillary  extra- 
vasations are  followed  by  more  or  less  oedema,  which  may 
extend  for  a  considerable  distance  into  the  surrounding  tissues. 
In  consequence  of  this  oedema  the  affected  portion  of  the 
brain  becomes  voluminous,  and  the  cut  surface  rises  above  the 
level  of  the  surrounding  tissues,  the  latter  of  which  assume 
different  shades  of  colour  from  the  imbibition  of  the  colouring 
matter  of  the  blood  set  free  in  the  central  part  of  the  effusion. 
When  the  inflamed  focus  presents  a  deep  red  colour  it  is  sur- 
rounded by  a  red  zone,  which  shades  off  into  brown,  then  into 
yellow,  and  finally  into  the  normal  colour  of  the  cerebral  tissue. 

The  'microscopic  changes  observed  in  the  first  stage  of 
inflammation  are  great  hypersemia  and  dilatation  of  the  vessels 
and  capillaries.  Hayem  asserts  that  he  has  seen  thevessels  dilated 
to  six  times  their  normal  calibre.  The  vessels  are  surrounded  by 
migrated  white  blood  corpuscles  and  the  tissues  are  infiltrated 
by  leucocytes,  probably  derived  from  multiplication  of  the  nuclei 
of  the  neuroglia  and  proliferation  of  the  cellular  elements  of 
the  walls  of  the  vessels.  A  large  number  of  granule  cells  (Gluge's 
corpuscles)  may  also  be  observed  in  the  inflamed  focus.  These 
are  probably  derived  from  the  ganglion  cells,  the  nuclei  of  the 
neuroglia,  the  nuclei  of  the  capillary  vessels,  and  the  endothelial 
cells  of  the  sheaths  of  the  vessels.  The  large  size  and  granular 
appearance  assumed  by  these  cells  are  supposed  by  Hayem  to  be 
due  to  the  absorption  of  nutriment  and  to  be  analogous  to  the 
cloudy  swelling  of  Virchow,  but  the  granular  appearance  is  at 
least  more  likely  to  be  caused  by  commencing  degeneration. 
The  ganglion  cells  swell  up,  their  protoplasm  undergoes 
molecular  disintegration,  and  after  the  inflammation  has  ceased 
they  undergo  various  degrees  of  atrophy  and  sclerosis,  and  in 
chronic  cases  the  calcification  and  pigmentary  infiltration 
described  by  Forster. 

§  818.  Further  Transformations  of  the  Primary  Focus. 
The  primary  focus  undergoes  various  changes  according  to  the  extent 
and  situation  of  the  inflammation.      In  a  large  proportion  of  cases  the 


DIFFUSED   DISEASES   OF  THE   ENCEPHALON.  737 

inflammatory  process  ceases  before  an  abscess  forms,  and  tlie  afiected  part 
presents  a  strong  resemblance  to  a  primary  necrosis  with  subsequent 
peripheral  encephalitis.  The  resulting  conditions  are  similar  in  the  two 
affections,  although  they  are  essentially  different  in  nature. 

(1)  An  encephalitis  of  slight  intensity  and  small  extent,  such  as  that 
caused  by  traumatic  contusion,  may  undergo  complete  repair. 

(2)  After  the  inflammatory  process  in  the  larger  foci  has  ceased  a  re- 
siduum is  left  behind  which  undergoes  the  well-known  destructive  changes, 
followed  by  absorption  of  the  fluid  contents.  All  the  cellular  elements 
in  the  focus  are  transformed  into  granule  cells,  which  undergo  a  gradual 
disintegration ;  the  contents  of  the  focus  becomes  thus  converted  into  a 
thick  emulsion,  coloured  brownish  or  yellowish  by  the  blood  pigment.  All 
the  nuclei  of  the  vessels  and  the  neuroglia,  and  the  white  blood  cells, 
which  are  enclosed  in  the  focus,  disappear,  and  its  contents  become  more 
homogeneous.  After  a  time  a  focus  of  yellow  softening  forms  which 
gradually  becomes  more  colourless,  and  at  last  may  be  transformed  into  a 
cavity  filled  by  a  thin  milky  fluid. 

(3)  But  the  focus  after  a  time  manifests  a  delicate  stroma  supplied  with 
delicate  vessels,  the  interspaces  of  which  are  filled  by  a  thin  turbid  fluid. 
The  stroma  consists  of  delicate  connective  tissue  supplied  with  vessels  ; 
the  formed  elements  of  the  fluid  consist  almost  wholly  of  large  quantities 
of  granular  fat  and  albuminous  bodies,  together  with  a  little  free  pigment. 
The  spaces  become  gradually  larger  and  the  fluid  clearer,  so  that  a  chasm 
remains  which  is  traversed  by  a  number  of  delicate  septa  of  connective 
tissue,  and  surrounded  by  somewhat  condensed  cerebral  substance.  Apo- 
plexy and  infarct  may  terminate  in  the  same  way,  and  the  nature  of  the 
preceding  affection  cannot  be  positively  determined  from  the  study  of  the 
lesions  in  their  later  stages. 

(4)  Local  encephalitis  may  lead  to  the  production  of  firm  sclerotic 
cicatrices  situated  usually  near  the  surface  of  the  brain,  more  rarely  deep 
in  the  interior  of  the  organ.  These  cicatrices  are  of  a  dirty-white  colour, 
tough,  and  firm ;  the  tissue  surrounding  them  is  atrophied,  so  that  the 
affected  hemisphere  is  less  than  the  other.  Even  distant  portions  of  the 
brain,  especially  of  the  cortex,  may  be  found  in  a  state  of  atrophy.  When 
the  cicatrices  are  situated  deep  in  the  brain,  cavities  are  found  within 
them  at  an  early  period.  At  a  later  period  the  cicatrix  contains  a  nucleus 
differing  from  the  rest,  and  containing  fat  and  pigment  grajiules,  hsexna- 
toidin  crystals,  and  amorphous  detritus. 

Such  inflammatory  processes  in  the  brain  very  seldom  become  quiescent ; 
they  are  followed  by  a  gradually  progressing  atrophy  of  the  entire  brain, 
which  causes  symptoms  during  life  that  even  at  the  present  day  are  fre- 
quently included  among  those  of  dementia  paralytica.  Hasse  has  also 
drawn  attention  to  the  fact  that  an  encephalitic  cicatrix  may  excite  fresh 
inflammation  at  a  later  period  resulting  in  the  development  of  a  new  zone 
V  V 


738  DIFFUSED  DISEASES   OF   THE   ENCEPHALON. 

of  red  softening  with  capillary  apoplexy.     It  may  also  excite  a  rapidly  pro- 
gressive yellow  softening,  which  may  prove  fatal. 

The  inflammation  excited  around  embolic  foci  may  give  rise  to  sclerotic 
capsules,  consisting  of  a  dense  fibrous  connective  tissue.  Huguenin 
examined  one  that  contained  a  large  number  of  spindle  cells  with  oblong 
nuclei,  which  he  surmised  to  have  been  derived  from  migrated  white 
blood  corpuscles. 

(5)  The  encephalitic  focus  may  be  transformed  into  a  collection  of  pus, 
which  may  be  subdivided  into  recent  and  old  abscesses.  An  abscess  is 
said  to  be  new  or  fresh  when  it  has  been  developed  rapidly  and  does  not 
possess  a  capsule,  but  this  distinction  does  not  hold  good  in  all  cases.  An 
acute  abscess  has  a  tendency  to  spread  in  every  direction  and  it  presents- 
an  irregular  cavity  in  the  substance  of  the  brain,  whose  walls  have  a 
rough,  shaggy  surface.  The  shaggy  projections  consist  of  shreds  of 
cerebral  tissiie,  which  are  attached  to  the  larger  blood-vessels.  The  tissue 
around  the  abscess  is  in  a  condition  of  red  softening,  and  in  many  j)laces 
the  softened  tissue  is  of  a  predominantly  yellow  colour ;  while  at  a  greater 
distance  from  the  focus  the  cerebral  tissue  is  oedematous.  As  the  pus  in 
the  central  cavity  accumulates  pressure  is  exerted  on  the  whole  of  the 
surrounding  tissue,  which  arrests  its  circulation  and  leads  to  fiui;her 
destruction,  and  advance  of  the  absftess. 

The  abscess  by  virtue  of  its  tendency  to  enlarge  may  reach  the  surface 
of  the  brain,  and  as  soon  as  perforation  occurs  an  acute  purulent  inflam- 
mation of  the  pia  mater  results. 

(6)  Old  abscesses  of  the  brain  possess  a  fibrous  capsule  which  may  attain 
a  thickness  of  several  millimetres.  Eindfleisch  afiirms  that  there  is  a 
gradual  transition  from  the  capsule  to  the  surrounding  nervous  tissue,  but 
the  connection  is  not  always  very  close,  inasmuch  as  the  abscess  can  be 
enucleated  without  much  difficulty.  The  internal  surface  of  the  hmiting 
membrane  is  smooth,  and  an  opaque  yellowish-white  appearance  is  given 
to  it  by  a  continuous  layer  of  cells  in  a  state  of  fatty  degeneration.  Out- 
side this  there  is  a  layer  of  embryonic  tissue. 

The  pus  of  the  abscess  is  of  a  greenish  colour,  and  greasy  consistency, 
is  odourless,  and  has  an  acid  reaction.  After  a  variable  period  of  quiescence 
the  abscess  enlarges  and  produces  manifold  changes  in  surrounding  parts. 
The  intracranial  pressure  becomes  increased,  the  nervous  tissue  in  the 
vicinity  of  the  abscess  may  be  compressed  so  that  its  nutrition  is  arrested, 
and  as  a-  result  there  follows  more  or  less  extensive  yellow  softening. 
Local  inflammatory  processes  in  more  distant  parts  are  met  with. 

Accessory  Changes  in  the  Brain. — Perforations  on  the  surface  of  the  brain 
and  into  the  ventricles  occur  in  connection  with  encapsulated  as  with 
recent  abscesses. 

Extensive  acute  cedema  of  the  brain  often  results  from  abscess,  and  is 
probably  due  to  the  increase  in  the  intracranial  pressure. 


DIFFUSED   DISEASES   OF   THE   ENCEPHALON.  739 

Anaemia  of  the  brain,  and  more  especially  of  the  cortex,  also  results 
from  the  increase  of  the  intracranial  pressure. 

Chronic  internal  hydrocephalus  results  whenever  an  abscess  is  situated 
in  the  cerebellum  in  such  a  position  that  it  lessens  the  cavity  of  the  foiu-th 
ventricle  or  of  the  Sylvian  aqueduct. 

§  819.  Diagnosis. — The  symptoms  of  abscess  of  the  brain 
are  very  similar  to  those  of  tumour,  but  the  two  affections  may 
generally  be  distinguished  by  the  history  of  the  case  and  the 
progress  of  the  symptoms.  Abscess  is  more  frequently  pre- 
ceded by  a  distinct  history  of  injury  to  the  head  than  tumour, 
although  the  latter  also  occasionally  develops  soon  after  injury 
to  the  skull.  The  course  pursued,  however,  by  the  two  affections 
subsequent  to  the  injury,  differs  widely.  If  the  symptoms  of 
acute  encephalitis  occur  immediately  after  the  injury,  and  be 
then  followed  by  a  remission  or  complete  intermission  and  break 
out  again  after  a  latent  period  of  variable  duration,  either  with 
or  without  the  phenomena  which  indicate  a  local  disease,  abscess 
may  be  diagnosticated  rather  than  tumour. 

If  the  other  causes  which  give  rise  to  abscess  of  the  bram, 
as  chronic  otorrhoea,  caries  of  the  temporal,  frontal,  or  nasal 
bones,  bronchiectasis  and  purulent  cavities  in  the  lungs  with 
putrid  secretions,  and  pyaemia  are  present,  along  with  the  symp- 
toms of  a  localised  lesion  of  the  brain,  then  also  the  existence 
of  an  abscess  rather  than  tumour  may  be  inferred. 

The  symptoms  of  tumour  are  sometimes  characterised  by 
frequent  remissions  and  exacerbations,  while  in  abscess  the 
symptoms  may  be  latent  or  stationary  for  a  comparatively 
long  time,  but  when  the  terminal  period  is  ushered  in  the 
remissions  are  of  short  duration  and  never  frequently  repeated. 
In  many  cases  of  tumour  the  course  of  the  disease  is  con- 
tinuous and  progressive  from  the  first,  and  the  symptoms 
increase  not  only  in  intensity  but  in  number  and  extent, 
the  general  symptoms  of  headache,  dizziness,  and  vomit- 
ing of  the  first  period  becoming  slowly  complicated  by  local 
spasms,  unilateral  convulsions,  pareses  passing  on  to  distinct 
paralyses,  sensory  disturbances,  slight  at  first  but  becoming 
more  profound,  and  various  disorders  of  the  special  senses. 
Although  these  symptoms  may  all  be  present  at  a  given  time  in 
the  course  of  chronic  abscess,  yet  they  never  appear  in  the  same 


740  DIFFUSED   DISEASES   OF  THE  ENCEPHALON. 

progressive  manner  in  the  latter  affection  as  they  do  in  tumour. 
Repeated  chilliness  and  slight  elevation  of  temperature  are 
more  characteristic  of  abscess  than  of  tumour,  but  it  must  be 
remembered  that  the  latter  is  liable  to  be  complicated  by 
attacks  of  acute  encephalitis. 

In  the  absence  of  a  distinct  history  of  the  case,  it  may  be 
impossible  to  distinguish  the  terminal  period  of  abscess  of  the 
brain  from  cerebral  haemorrhage,  or  occlusion  of  a  large  vessel ; 
but  if  there  be  a  history  of  inj  ury  to  the  skull,  followed  by  the 
symptoms  of  acute  encephalitis,  then  the  diagnosis  is  less 
difficult.  This  difficulty  is  likely  to  arise  when,  after  a  long 
latent  period,  the  abscess  makes  its  way  into  the  ventricles,  or 
when  sudden  oedema  of  the  brain  occurs.  When  the  abscess 
ruptures  on  the  surface  of  the  brain  the  terminal  symptoms  are 
those  of  acute  meningitis,  and  the  diagnosis  between  primary 
meningitis  and  abscess  must  again  be  made  from  the  history  of 
the  case  and  the  symptoms. 

Abscess  of  the  brain  is  difficult  to  distinguish  from  necrotic 
softening.  The  diagnosis  must  be  made  on  the  one  hand  by 
the  history  of  an  injury  to  the  skull  or  the  presence  of  one  of 
the  other  causes  which  give  rise  to  abscess ;  and  on  the  other 
hand  by  a  careful  general  examination  of  the  patient,  especially 
of  the  organs  of  circulation,  to  ascertain  the  presence  or  not'  of 
the  conditions  which  lead  to  embolism  or  thrombosis. 

§  820.  Prognosis. 

(a)  Meningo- Encephalitis. — A  superficial  contusion  of  the 
brain  usually  terminates  in  acute  suppuration  associated  with 
meningitis,  and  the  affection  is  generally  fatal.  Recovery  is 
possible  only  when  diffuse  meningitis  does  not  take  place,  and 
when  the  pus  is  discharged  through  a  wound,  produced  either 
by  the  original  injury  or  by  surgical  operation. 

(6)  Suppurative  encephalitis  without  accompanying  me- 
ningitis, resulting  from  contusion  of  the  brain,  does  not  appear 
to  be  capable  of  spontaneous  absorption.  Recovery,  however, 
may  take  place  either  from  spontaneous  perforation  externally 
or  from  artificial  evacuation.  Acute  abscess  may,  instead  of 
at  once  terminating  fatally,  pass  into  the  chronic  form. 

(c)  Chronic  traumatic  abscess  of  the  brain  is,  as  a  rule,  fatal. 


DIFFUSED   DISEASES   OF  THE   ENCEPHALON,  741 

A  small  number  of  cases  have  recovered  spontaneously  after 
perforation  through  the  skull.  The  pus  has  been  evacuated  by 
fortunate  trephining,  but  the  number  of  cases  in  which  the 
patient  was  saved  is  small. 

(d)  Otorrhoeal  Abscess  of  the  Brain. — Several  cases  of  re- 
covery of  otorrhoeal  cerebral  abscess  are  on  record  in  which  the 
pus  made  its  way  through  the  diseased  ear.  Acute  otorrhoeal 
abscess  of  the  brain  often  passes  into  the  chronic  form,  but  the 
ultimate  prognosis  in  both  varieties  is  unfavourable. 

(e)  Pycemic  Abscesses  of  the  brain,  whatever  may  be  their 
cause,  are  always  fatal. 

(/)  Acute  Traumatic  Encephalitis  without  formation  of 
Pus. — Cases  of  recovery  from  undoubted  traumatic  encephalitis 
have  been  collected  by  Bruns.  The  prognosis  of  encephalitis 
around  chronic  abscesses,  tumours,  chronic  softening,  and 
apoplexies  depends  upon  the  nature  and  extent  of  the  primary 
disease.  The  prospect  is  least  favourable  in  abscess  and  tumour. 
The  age  and  strength  of  the  patient  is  an  important  factor  in 
estimating  the  danger  of  encephalitis  secondary  to  necrotic 
softening  and  cerebral  hasmorrhage,  but  the  complication  is 
always  a  serious  one,  and  even  if  the  patient  survive  the 
general  and  local  symptoms  are  usually  aggravated  by  an  in- 
crease in  the  destruction  of  tissue  caused  by  the  primary  focus. 

§  821.  Treatment. — The  physician's  advice  may  be  sought  to 
aid  the  surgeon  in  determining  questions  of  cerebral  localisation, 
and  the  other  delicate  points  of  diagnosis  which  are  likely  to 
arise  in  the  progress  of  such  cases,  but  the  decision  with  regard 
to  the  treatment  to  be  adopted  must  rest  with  him. 

The  secondary  inflammation  which  is  liable  to  supervene  in 
the  course  of  necrotic  softening,  cerebral  haemorrhage,  and 
intracranial  tumours  is  the  form  of  encephalitis  which  is  most 
likely  to  come  under  the  care  of  the  physician.  This  variety 
is  best  treated  by  complete  rest  in  a  darkened  room,  mild 
purgation,  and  cold  applied  to  the  head  ;  more  active  measures 
like  bleeding  and  blistering  are  worse  than  useless. 

Chronic  abscess  of  the  brain  does  not  admit  of  any  special 
medical  treatment,  but  the  general  health  of  the  patient  must 
be  attended  to,  and  his  diet  and  habits  carefully  regulated. 


742  DIFFUSED  DISEASES  OF  THE   ENCEPHALON. 

Paroxysms  of  severe  headache  may  sometimes  be  relieved  by 
chloride  of  ammonium,  while  more  active  symptoms  like 
delirium  may  be  combated  by  bromide  of  potassium,  either 
alone  or  in  combination  with  chloral,  and  an  opiate  may  some- 
times be  found  useful.  Drs.  Russell  Reynolds  and  Hammond 
speak  favourably  of  Cannabis  Indica  in  the  treatment  of  the 
more  active  sympton^s  of  suppurative  encephalitis. 


743 


CHAPTER    XIV. 


DISEASES  OF   THE   MEMBRANES   OF  THE   BRAIN. 


I.   DISEASES  OF    THE  DURA   MATER. 

Inflammation  of  the  dura  mater  may  be  divided  into  (i.) 
external,  and  (ii.)  internal  pachymeningitis. 

(i.)    External  Pachymeningitis. 
External  pachymeningitis  consists  of  inflammation  of  the 
outer  lamella  of  the  dura  mater. 

§  822.  Etiology. — The  chief  causes  of  the  affection  are  the 
following : — 

1.  Injuries  which  detach  the  dura  mater  from  the  inner  sur- 
face of  the  skull,  and  occasion  an  extravasation  of  blood 
between  them.  The  clot  may  be  so  large  as  to  compress  the 
brain  and  cause  death  in  a  short  time.  At  other  times  inflam- 
mation is  set  up  in  the  surrounding  tissues  and  the  bone  is 
threatened  with  necrosis. 

2.  Perforating  injuries  of  the  skull,  as  incised,  punctured, 
and  bullet  wounds,  which  either  -directly  or  indirectly  injure 
the  dura  mater. 

3.  Extension  of  inflammation  from  neighbouring  tissues. 
Caries  of  the  petrous  portion  of  the  temporal  bone  is  one  of 
the  most  frequent  causes  of  external  pachymeningitis,  and  it 
usually  gives  rise  to  the  suppurative  form  of  inflammation. 

Purulent  inflammation  of  the  external  lamella  may  also 
follow  caries  of  other  cranial  bones,  especially  the  ethmoid  and 
the  flat  bones  of  the  skull,  as  well  as  by  caries  of  the  upper 
cervical  vertebrse  and  their  ligaments. 


744  DISEASES  OF  THE  MEMBRANES   OF   THE   BRAIN. 

4.  The  external  layer  of  the  dura  mater  is  subject  to  chronic 
fibrous  thickening  in  old  age,  and  becomes  adherent  to  the  bone. 

§  823.  Symptoms. — In  the  traumatic  form  of  external  pachy- 
meningitis the  patient  may  recover  from  the  immediate  effects 
of  the  injury,  and  appear  for  a  time  in  perfect  health.  At 
the  end  of  two  or  three  weeks  he  complains  of  pain  in  the 
head,  is  feverish,  and  should  there  be  an  external  wound,  it 
assumes  an  unhealthy  aspect.  If  the  inflammation  spread 
further,  the  headache  increases  in  intensity,  and  the  patient 
suffers  from  vertigo,  nausea,  and  vomiting,  while  monospasms 
or  unilateral  convulsions  may  occur  if  the  motor  area  of  the 
brain  be  implicated.  The  internal  membranes  of  the  brain 
now  become  affected,  the  previously  convulsed  limbs  become 
paralysed,  the  patient  becomes  delirious,  and  fatal  coma  soon 
supervenes. 

When  an  abscess  forms  between  the  dura  mater  and  the 
bones  of  the  skull,  the  symptoms  may  be  those  of  gradual 
cerebral  compression,  and  when  it  is  situated  over  the  motor 
area  of  the  cortex,  monospasms  or  monoplegise  may  result. 

The  pachymeningitis  of  old  age  is  often  discovered  after 
death  without  having  been  suspected  during  life.  In  other 
cases  the  meningitis  may  have  manifested  itself  merely  by  a 
persistent  dull  headache.  After  death  atrophy  of  the  brain, 
compensatory  hydrocephalus,  and  serous  infiltration  of  the  pia 
mater  are  observed. 

§  824.  Morbid  Anatomy. — The  dura  mater  is  at  first  con- 
gested, and  presents  punctiform  extravasations.  In  a  more 
advanced  stage  the  membrane  becomes  swollen  and  infiltrated 
with  numerous  white  blood  corpuscles.  These  cells  may  after 
a  time  become  transformed  into  spindle  cells,  and  ultimately 
developed  into  bundles  of  connective  tissue.  Portions  of  the 
membrane  may  sometimes  become  ossified. 

If  the  inflammation  progress  to  actual  suppuration,  the 
white  blood  corpuscles  become  more  numerous,  and  make  their 
way  through  the  internal  lamella  to  the  free  surface,  so  that  a 
purulent  internal  pachymeningitis  is  added  to  the  external 
pachymeningitis.     At  times,  however,  the  abscess  is  cut  off 


DISEASES   OF  THE  MEMBRANES   OF   THE  BRAIN.  745 

from  the  internal  layer  by  the  development  of  adhesions,  and 
in  that  case  the  external  layer  becomes  disintegrated,  soft, 
and  friable;  while  the  internal  layer  becomes  adherent  to  the 
pia  mater  and  brain.  In  the  large  majority  of  cases  the  in- 
flammation spreads  to  the  internal  lamella. 

§  825.  Prognosis. — The  prognosis  in  traumatic  cases  turns 
on  the  possibility  of  the  pus  finding  a  free  escape.  If  a  free 
discharge  can  be  obtained,  the  affection  of  the  dura  mater  may 
occasion  but  little  trouble ;  while,  on  the  other  hand,  if  the 
matter  is  pent  up,  grave  symptoms  must  result,  both  on  account 
of  the  increased  intracranial  pressure,  and  the  rapidity  with 
which  the  suppurative  process  spreads.  The  prognosis  of  puru- 
lent inflammation  of  the  dura  mater  resulting  from  caries  of 
the  petrous  portion  of  the  temporal  bone  is  very  unfavourable. 

§  826.  Treatment. — The  treatment  of  the  acute  stage  must 
be  conducted  according  to  general  principles.  The  question  of 
trephining  will  arise  in  connection  with  the  formation  of  an 
abscess  or  extravasation  of  blood  between  the  dura  mater  and 
the  bone,  but  this  belongs  to  surgery. 

(ii.)   Internal  H^moeehagic  Pachymeningitis. 
( Hcematoma  of  the  Dura  Mater.) 

§  827.  Etiology. — Hsematoma  is  associated  with  all  those 
diseases  which  profoundly  affect  nutrition,  and  many  of  them 
are  diseases  like  scorbutus,  in  which  haemorrhages  are  liable 
to  occur  in  other  parts  of  the  body.  The  disease  is  found  in 
atrophy  of  the  brain  accompanied  by  oedema  of  the  pia  mater 
and  hydrocephalus  internus.  On  the  whole,  therefore,  it  seems 
probable  that  when  hasmatoma  of  the  dura  mater  does  not 
result  from  direct  injury,  it  is  caused  either  by  constitutional 
disease  producing  profound  alteration  in  the  quality  of  the 
blood,  degeneration  of  the  vessels  of  the  brain,  or  by  diseases 
associated  with  passive  congestion  of  the  brain.  It  is  not 
therefore  surprising  that  the  affection  should  occur  chiefly  in 
old  age. 

§  828.  Symptoms. — The  symptoms  of  hsematoma  vary 
greatly  in  different  cases,  but  the  following  are  the  more 
usual : — 


746  DISEASES   OF  THE   MEMBRANES   OF  THE   BEAIN. 

Headache  is  a  very  constant  symptom,  being  rarely  absent. 
The  pain  is  described  as  if  something  were  moving  about  in  the 
head,  or  as  a  throbbing  accompanied  by  a  sensation  of  pressure 
in  the  head.  The  pain  is  not  accurately  localised,  but  is  some- 
times more  violent  on  the  side  of  the  hoematoma.  It  is  much 
increased  when  a  fresh  haemorrhage  occurs;  but  if  there  be  great 
atrophy  of  the  brain,  as  in  dementia  paralytica  and  in  cases  of 
senile  atrophy,  a  hsematoma  may  attain  a  considerable  size 
without  causing  much  headache.  On  the  other  hand,  when 
there  is  no  shrinking  of  the  brain  a  thin  layer  of  blood  causes 
violent  pain. 

The  motor  disturbances  consist  of  muscular  twitchings  of 
one  or  both  sides,  followed  by  rigidity.  In  other  cases,  paresis 
first  of  one  and  then  of  the  other  extremity  of  the  same  side 
occurs  followed  by  distinct  hemiplegia,  the  facial  and  hypoglossal 
nerves  becoming  involved.  In  some  cases  the  paralysis  extends 
to  the  other  side,  showing  either  that  the  affection  has  spread 
to  the  opposite  hemisphere,  or  that  a  fresh  haemorrhage  has 
occurred.  Impairment  of  co-ordinate  movements  frequently 
occurs,  as  uncertainty  of  gait,  difficulty  in  writing  and  speaking. 
Conjugate  deviation  of  the  eyeballs  towards  the  side  of  the  lesion 
is  not  unfrequently  observed,  but  strabismus  and  ptosis  rarely 
if  ever  occur. 

Sensory  disturbances  are  not  very  common  symptoms. 
Patients  sometimes  complain  of  formication  and  numbness 
on  the  paralysed  side,  but  impairment  of  sensation  in  the 
absence  of  paralysis  is  not  met  with. 

Psychical  disturbance  occurs  in  a  large  number  of  cases. 
This  is  sometimes  due  to  the  primary  disease,  as  in  dementia 
paralytica,  while  in  other  cases  it  is  due  directly  to  the  haemor- 
rhage. Symptoms  of  irritation  are  present  in  the  beginning, 
evinced  by  great  mental  irritability,  abnormal  sensitiveness  to 
light,  and  ringing  in  the  ears,  but  these  soon  give  place  to  those 
of  compression.  In  other  cases  the  disease  begins  by  a  regular 
attack  of  apoplexy. 

Drowsiness  is  an  important  symptom,  and  Griesinger  has 
called  attention  to  its  occurrence  in  connection  with  contracted 
pupils  and  chronic  headache,  but  at  times  dilatation  of  the 
pupils  is  observed. 


DISEASES   OF  THE  MEMBRANES   OF   THE   BRAIN.  747 

Slowness  of  the  pulse  occurs  in  the  majority  of  cases  during 
the  haemorrhage,  but  the  quickness  of  the  pulse  varies,  and  it 
becomes  frequent  and  irregular  before  death. 

The  pupils  are  generally  contracted  and  insensible  to  light 
during  the  irritative  stage,  but  dilatation  predominates  when 
the  symptoms  of  compression  supervene. 

§  829.  Varieties. — The  symptoms  may  be  subdivided  into 
several  groups,  according  to  the  extent  and  localisation  of  the 
hsemorrhage  and  the  diseases  with  which  it  is  associated. 

1.  In  the  first  group  the  hsemorrhage  is  so  severe  from  the  beginning 
that  death  soon  occurs,  and  in  these  cases  the  symptoms  cannot  be 
distinguished  from  those  of  ordinary  apoplexy.  Contractures  of  the 
extremities  and  slight  transitory  twitches  are  sometimes  observed  in  these 
cases,  and,  as  a  rule,  the  pupil  is  more  contracted  and  fixed  in  haematoma 
than  in  intra-cerebral  hsemorrhage.  In  a  smaU  number  of  cases  the 
extravasations  on  one  side  cause  convulsive  movements  of  the  opposite 
side;  but  the  compression  soon  becomes  so  great  that  the  irritability 
of  the  cortex  is  abolished. 

2.  In  a  certain  number  of  cases  extravasations  are  found  after  death, 
though  there  had  been  no  suspicion  of  their  existence  during  life.  These 
haemorrhages,  however,  are  usually  small,  and  are  generally  found  in 
cases  of  dementia  paralytica. 

3.  In  a  third  series  the  symptoms  are  at  first  slight,  but  gradually 
increase  in  severity  and  soon  prove  fatal.  The  chief  symptom  in  the 
beginning  is  severe  cephalalgia,  with  or  without  vertigo,  followed  by 
drowsiness  increasing  gradually  to  sopor,  and  ending  in  profound  coma. 
The  pupils  are  contracted  in  the  early  stage,  but  when  coma  supervenes 
they  gradually  dilate  and  may  become  unequal.  Hemiparesis  generally 
shows  itself  on  the  side  opposite  to  the  lesion,  while  symptoms  of  irritation 
may  appear  on  the  same  side,  but  after  a  time  all  the  extremities  may 
be  paralysed.  Similar  symptoms  are  caused  by  any  meningeal  affection, 
and  especially  by  tubercular  meningitis.  In  establishing  a  diagnosis, 
therefore,  the  conditions  under  which  the  disease  has  developed  must  be 
taken  into  account.  Hsematoma  is  more  likely  to  be  present  in  old  per- 
sons, when  atrophy  of  the  brain  is  to  be  suspected ;  tubercular  meningitis, 
on  the  other  hand,  usually  occurs  in  young  persons. 

4.  In  a  fourth  series  of  cases  recovery  takes  place  from  a  first  hsemor- 
rhage, but  after  an  interval  of  apparent  health  a  second  occurs  which 
results  in  death.  In  these  cases  unilocular  or  multilocular  sacs  are  found 
on  one  or  both  sides,  and  one  of  the  subordinate  sacs  always  contains  a 
considerable  effusion  of  blood  which  has  caused  death  by  compression. 


748  DISEASES   OF  THE  MEMBRANES   OF  THE  BRAIN. 

§  830.  Course,  Duration,  and  Terminations. — The  course  of 
the  affection  is  extremely  variable,  but  it  usually  begins  with 
more  or  less  acute  symptoms,  followed  by  an  interval  of  com- 
parative health ;  after  a  time,  however,  a  fresh  acute  attack 
occurs  which  may  lead  to  death  or  be  followed  by  a  second 
interval. 

During  the  interval  the  symptoms  are  those  indicating  a 
lesion  which  produces  a  certain  amount  of  irritation  along 
with  compression  of  the  brain.  These  consist  of  cephalalgia, 
diminution  of  intelligence,  impairment  of  memory,  drowsiness, 
partial  paralyses,  disturbances  of  speech,  and  sudden  mental 
excitement  without  cause,  frequently  mixed  with  symptoms  of 
dementia  paralytica. 

The  duration  of  the  affection  is  not  well  known,  inasmuch 
as  it  is  not  always  possible  to  fix  with  accuracy  its  commence- 
ment. The  majority  of  cases  of  pachymeningitis  end  fatally, 
but  recovery  may  take  place  in  many  cases,  only  traces  of  the 
affection  remaining,  such  as  a  slight  degree  of  paresis,  head- 
ache, sleeplessness,  and  some  weakness  of  intelligence. 

§  831.  Morbid  Anatomy. — Hsemorrhagic  pachymeningitis 
presents  itself  as  an  organised  mass  situated  between  the  dura 
mater  and  surface  of  the  arachnoid,  and  presenting  different 
appearances  in  different  cases.  Various  opinions  have  been 
entertained  with  respect  to  the  seat  and  nature  of  the  affection, 
but  the  explanation  which  was  first  given  by  Virchow  is  now 
pretty  generally  accepted  by  pathologists.  According  to  this 
view  the  pachymeningitis  begins  with  hypersemia  of  the  dura 
mater,  occupying  generally  the  area  supplied  by  the  middle 
meningeal  artery.  The  inner  surface  of  the  dura  mater  assumes 
a  rosy  colour,  and  after  a  time  a  loose  yellowish  coating  forms, 
which  is  dotted  with  a  number  of  confluent  or  separate  hsemor- 
rhagic  points. 

This  coating  can  be  stripped  from  the  dura  mater,  tearing 
many  small  vessels  which  enter  its  substance.  Rindfleisch  says 
that  this  membrane  is  rich  in  vessels,  which  are  usually  three 
times  as  large  as  capillaries  and  present  varicosities.  The 
basis  substance  between  the  vessels  is  composed  of  star-shaped 
connective  tissue   cells.     Emigrant  corpuscles  pass   from    the 


DISEASES   OF   THE   MEMBRANES   OF   THE  BRAIN.  749 

blood-vessels  of  the  sub-epithelial  layer  of  the  dura  mater,  and 
develop  into  a  loose  connective  tissue.  Hsemorrhages,  varying 
in  quantity  at  different  times,  take  place  from  the  vessels  which 
enter  the  false  membrane ;  the  clots  become  partially  organised, 
and  the  delicate  capillaries  which  develop  in  them  become  the 
source  of  new  hasmorrhages,  so  that  a  large  quantity  of  blood 
may  in  this  manner  be  poured  out  between  the  thickened 
membranes.  It  is  right,  however,  to  state  that  Huguenin  be- 
lieves that  the  first  stage  of  hsematoma  is  not  the  formation  of 
a  false  membrane,  but  simply  an  extravasation  of  blood  on  the 
inner  surface  of  the  dura  mater,  which  undergoes  the  changes 
which  usually  take  place  in  a  coagulum.  This  coagulum  under- 
goes partial  organisation  so  as  to  form  a  vascular  layer,  from 
which  haemorrhage  takes  place,  giving  rise  to  further  extrava- 
sation, which  in  its  turn  becomes  organised. 

Pachymeningitis  hsemorrhagica  is  most  frequently  found  in 
the  upper  part  of  the  brain  along  the  falx  cerebri,  spreading 
down  the  curved  portion  of  the  frontal  and  occipital  lobes,  and 
laterally  towards  the  Sylvian  fissure.  Kremiansky  found  that 
in  fifty-four  out  of  sixty-five  cases  its  extent  exactly  corre- 
sponded to  the  parietal  bones.  In  cases  of  dementia  paralytica, 
in  which  the  brain  is  frequently  found  shrunk  and  atrophied, 
the  blood  often  extends  much  further,  and  may  reach  the  base 
of  the  brain.  In  rather  more  than  half  of  the  cases  described 
the  haemorrhage  extended  over  the  surfaces  of  both  hemispheres, 
while  in  the  remainder  it  was  limited  to  one  hemisphere. 

Changes  in  the  skull  have  been  described  by  various  authors, 
but  none  of  them  are  constantly  present ;  some  of  these,  such 
as  elevation,  thinning,  and  thickening  of  the  bones,  are  in  all 
probability  anomalies,  which  are  entirely  independent  of  the 
hsematoma.  Osteophytes  on  the  inner  surface  of  the  skull 
have  been  described  by  Rokitansky  and  Cruveilhier. 

The  pia  mater  is  often  the  seat  of  changes,  such  as  are  found 
in  atrophy  of  the  brain,  consisting  of  slight  opacities,  oedema, 
and  small  fibrous  thickenings. 

The  substance  of  the  brain  is  variously  affected  according  to 
the  thickness  of  the  hsematoma.  The  thin  extravasations  and 
membranes  do  not  cause  any  marked  changes  in  the  brain,  but 
large  hsematomata  compress  it,  and  produce  consecutive  anaemia 
and  atrophy. 


750  DISEASES   OF   THE   MEMBRANES   OF   THE  BRAIN. 

The  hrain  is  often  found  atrophied  and  contracted  indepen- 
dently of  the  hsematoma.  The  decrease  in  the  size  and  weight 
of  the  brains  of  drunkards,  and  senile  atrophy  are  important 
factors  in  the  production  of  hsematoma.  The  affection  is  fre- 
quently associated  with  atheroma  and  calcification  of  the  intra- 
cranial arteries.  Diffused  sclerosis  and  the  chronic  degeneration 
which  accompanies  dementia  paralytica  are  often  associated 
with  hsematoma.  A  glance  at  all  the  varied  changes  found 
associated  with  hsematoma  will  show  that  this  affection  in  the 
great  majority  of  cases  occurs  along  with  alterations  which 
occasion  a  reduction  in  the  size  of  the  brain. 

§  832.  Prognosis. — The  prognosis  depends  in  great  measure 
upon  the  fundamental  affection  which  is  present  along  with 
the  pachymeningitis.  It  is  always  grave,  although  not  neces- 
sarily fatal. 

§  833.  Treatment — The  treatment  of  hsematoma  of  the  dura 
mater  will  greatly  depend  upon  the  underlying  affection,  and  it 
it  is  consequently  desirable  to  examine  carefully  for  disease  of 
other  organs.  If  venous  stasis  be  present,  a  small  bleeding  or 
a  smart  watery  purgative  gives  temporary  relief  to  the  circula- 
tion, but  energetic  antiphlogistic  treatment  must  be  carefully 
avoided. 

During  the  stage  of  hsemorrhage  ice  should  be  applied  to  the 
head;  but  counter-irritation,  if  used  at  all,  should  be  reserved 
for  a  later  period.  The  patient  must,  of  course,  be  kept  quiet 
and  all  excitement  prevented. 


751 


CHAPTER   XV. 


DISEASES    OF    THE    MEMBRANES    OF    THE    BRAIN 

(Continued). 


II.    DISEASES    OF   THE    PIA   MATER. 

Inflammation  of  the  Pia  Mater  (Leptomeningitis J. 

HypeRjEMIA  of  the  pia  mater  is  always  accompanied  by  con- 
gestion of  the  brain,  and  does  not  demand  separate  notice. 
Attempts  have  been  made  to  distinguish  inflammations  of  the 
visceral  layer  of  the  arachnoid  from  those  of  the  pia  mater, 
but  anatomists  are  now  agreed  that  the  former  membrane  is 
only  the  thickened  external  layer  of  the  latter,  and  clinical 
records  show  that  in  the  cases  of  so-called  arachnitis  the  in- 
ternal layer  of  the  pia  mater  is  always  affected. 

1.  Leptomeningitis  Infantum  (Hydrocephalus  sine  Tuberculis). 

Acute  inflammation  of  the  pia  mater  may  occur  in  infancy 
in  the  entire  absence  of  tubercle,  and  the  simple  like  the 
tubercular  variety  is  attended  by  effusion  into  the  ventricles 
of  the  brain.  Acute  ventricular  effusion  from  simple  inflam- 
mation  of  the  pia  mater  is  most  common  in  children  between 
one  and  two  years  of  age,  but  sometimes  occurs  in  younger  and 
sometimes  in  older  children. 

§  884.  Symptoms. —  The  clinical  history  of  this  affection 
may  vary  in  no  important  particular  from  that  of  tubercular 
meningitis,  but  the  premonitory  symptoms  are  not  so  well 
marked  in  the  former  as  in  the  latter. 

The  symptoms  of  the  period  of  invasion  differ  considerably 


752  DISEASES   OF  THE  MEMBRANES   OF  THE  BRAIN, 

in  individual  cases.  Some  cases  begin  with  slight  fever,  which 
may  be  symptomatic  of  the  meningitis  or  of  another  affection, 
and  the  febrile  condition  may  be  ushered  in  by  an  attack  of 
convulsions.  In  meningitis  the  symptoms  of  intense  cerebral 
hypersemia  are  soon  superadded  to  those  of  ordinary  pyrexia. 
In  other  cases  violent  headache  is  the  first  symptom,  and 
vomiting  is  frequently  present.  The  child  is  restless,  the  eye- 
lids are  only  half  closed  during  sleep,  the  eyeballs  roll  about, 
the  pupils  are  contracted  but  react  well  to  light,  and  there  may 
be  slight  convulsive  twitchiag  of  the  extremities  but  there  is 
no  paralysis.  The  children  are  abnormally  sensitive  to  light 
and  sound,  and  the  lightest  touch  on  the  skin  may  cause  pain. 
Older  children  are  either  unable  to  stand,  or  totter  when  they 
attempt  to  walk,  they  complain  of  buzzing  in  the  ears,  are 
fretful,  morose,  and  taciturn.  In  younger  children  the  fonta- 
nelles  may  be  seen  to  pulsate  strongly,  but  they  are  not  arched. 
The  countenance  has  a  vexed  or  angry  expression.  The  features 
are  at  times  distorted,  the  forehead  is  wrinkled,  and  a  distress- 
ing moan  is  frequently  uttered. 

These  symptoms  may  continue  for  two  or  three  days,  and 
then  the  child  may  be  attacked  by  convulsions.  These  begin 
by  conjugate  deviation  of  the  eyes  and  rotation  of  the  head, 
the  upper  and  lower  extremities  of  one  side  are  chiefly  affected, 
and  then  the  spasms  cross  over  to  the  opposite  side,  when  the 
convulsion  becomes  general.  The  state  of  the  pupils  vary,  but 
they  are  generally  dilated  and  fixed  during  the  convulsions. 
The  temperature  rises  during  the  attack,  and  may  exceed 
104°  F. 

Death  may  occasionally  occur  suddenly  during  the  attack, 
and  when  the  convulsion  is  not  fatal  the  subsequent  course 
of  the  affection  is  marked  by  an  aggravation  of  the  cerebral 
symptoms.  Young  children  lie  in  a  disturbed  sleep,  with  the  eye- 
lids tightly  closed,  and  showing  evidence  of  pain  by  wrinkling 
of  the  brow  and  moaning,  but  the  pulsation  of  the  fontanelles 
may  now  diminish  owing  to  the  distension  of  the  ventricles  by 
effusion.  Older  children  lie  for  hours  in  a  state  of  stupor,  they 
are  listless  and  indifferent,  and  do  not  appear  to  see  distinctly, 
or  they  may  be  absolutely  blind.  The  pulse  is  very  variable  in 
rate   at   different   times.     The    respirations    are    sighing  and 


DISEASES   OF   THE   MEMBRANES   OF  THE   BRAIN.  753 

irregular.  The  temperature  continues  more  or  less  elevated, 
but  its  course  is  very  irregular.  Persistent  vomiting  and 
obstinate  constipation  are  common,  while  the  power  of  deglu- 
tition may  be  impaired  at  an  early  period. 

The  child  rapidly  emaciates,  the  skin  is  dry,  with  the 
exception  of  that  of  the  face,  which  may  be  bathed  with  per- 
spiration. 

The  patient  now  sinks  into  a  condition  of  profound  coma, 
but  tetanic  spasms  of  the  muscles  of  the  neck  and  extremities 
may  persist  for  a  time. 

The  temperature  often  falls  below  normal  before  death,  but 
hyperpyrexia  has  been  observed  in  rapidly  fatal  cases.  The 
pulse  then  becomes  very  rapid,  irregular,  and  intermittent. 

§  835.  Course,  Duration,  and  Terminations. —  Complete 
recovery  may  take  place,  probably  even  after  effusion  has 
occurred,  but  as  a  rule  recovery  is  partial,  and  the  patient 
subsequently  suffers  from  mental  feebleness  or  depraved  moral 
character.  In  the  latter  case  the  cortex  of  the  brain  has  pro- 
bably undergone  some  degree  of  atrophy  from  the  pressure  of 
the  effusion.  The  majority  of  cases  terminate  fatally  in  from 
nine  to  fourteen  da,ys,  some  die  at  an  earlier  period  in  an  attack 
of  convulsions,  while  in  other  cases  the  disease  may  be  pro- 
tracted beyond  thirty  days,  its  course  being  marked  by  remis- 
sions and  exacerbations. 

§  836.  Morbid  Anatomy. — The  cranial  bones  present  dif- 
ferent degrees  of  congestion,  and  the  fontanelles  are  distended. 
The  convolutions  of  the  brain  are  flattened  and  the  sulci  oblite- 
rated, owing  to  the  pressure  exerted  by  the  distended  ventricles. 
The  fluid  is  never  found  between  the  dura  and  outer  layer  of 
the  pia  mater,  and  the  oiiter  surface  of  the  latter  is  usually  re- 
markably dry.  The  cortex  and  white  substance  are  compressed 
and  but  moderately  filled  with  blood,  and  no  capillary  extrava- 
sations are  found  in  the  cortex.  The  dilatation  of  the  ventricles 
is  usually  symmetrical,  and  a  considerable  amount  of  softening 
not  unfrequently  exists  around  the  ventricles,  but  this  may  be 
due  to  post-mortem  changes. 

The  choroid  plexuses  are  unusually  voluminous,  they  often, 
w  w 


754  DISEASES   OF   THE   MEMBKANES   OF   THE   BRAIN. 

contain  punctiform  extravasations,  and  the  aqueduct  of  Sylvius 
and  fourth  ventricle  are  often  dilated  and  distended  with  fluid. 
No  exudation  is  found  at  the  base  of  the  brain. 

§  8S7.  Prognosis. — The  prognosis  is  always  unfavourable, 
although  a  few  cases  recover  either  partially  or  completely. 

§  838.  The  diagnosis  will  be  discussed  in  connection  with 
tubercular  meningitis,  and  the  treatment  of  the  two  affections 
is  the  same. 

2.  Tubercular  Meningitis  {Acute  Hydrocephalus). 

§  839.  Etiology. — Most  of  those  who  suffer  from  tubercular 
meningitis  belong  to  families  in  which  the  tubercular  diathesis 
is  distinctly  marked.  The  influence  which  improper  nourish- 
ment, want  of  pure  air  and  light,  exposure  to  cold  and  damp^ 
and  neglected  hygiene  exerts  in  the  production  of  tuber- 
cular affections  generally  is  well  known.  It  is  not  surprising 
therefore,  to  find  that  the  largest  proportion  of  cases  of  tuber- 
cular meningitis  should  occur  in  crowded  populations  and  large 
cities,  and  amongst  the  poorest  and  most  neglected  part  of  the 
population.  Season  does  not  appear  to  exert  any  influence  in 
the  production  of  the  disease.  Tubercular  meningitis  may  set 
in  at  any  age,  but  it  is  much  more  frequent  between  the  ages 
of  two  and  seven  years.  The  numbers  diminish  from  the  seventh 
to  the  tenth,  and  in  still  greater  proportion  from  the  tenth  to 
the  fifteenth.  It  is  most  common  in  adults  between  the  ages  of 
twenty  and  forty,  and  occurs  very  exceptionally  after  the  forty- 
fifth  year.  The  male  sex  appears  to  be  more  frequently  affected 
than  the  female.  In  adults  the  proportion  is  51"5  men  to  48'5 
women  (Huguenin) ;  and  the  proportion  of  males  affected  in 
children  is  still  greater. 

§  840.  Symptoms. — Various  premonitory  symptoms  manifest 
themselves  for  a  variable  period  of  weeks  or  months  before  the 
development  of  the  distinctive  phenomena  of  tubercular  menin- 
gitis. The  most  constant  precursor  of  the  affection  is  a  gradual 
loss  of  flesh  without  any  perceptible  cause,  and  this  is  more 
noticeable  in  the  trunk  and  limbs  than  in  the  face.  There  is 
loss  of  appetite,  the  bowels  are  constipated,  or  diarrhoea  may 


DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN.  755 

alternate    with    constipation,    and    the    patient    complains    of 
weariness  and  an  undefined  feeling  of  illness. 

The  premonitory  symptoms  are  better  marked  in  the  case  of 
children.  The  child  loses  his  vivacity,  becomes  sad,  fretful, 
taciturn,  irritable,  and  wants  to  be  left  alone,  and  in  the  midst 
of  play  leaves  his  companions  in  order  to  give  vent  to  his 
distress  in  tears.  The  child  sleeps  with  eyes  half  open,  starts., 
and  cries  out ;  he  grinds  his  teeth,  and  his  sleep  is  disturbed  by 
muscular  twitches  and  horrible  dreams. 

Headache  is  generally  present,  and  after  a  time  a  slight  febrile 
accession  is  observed  towards  evening  without  obvious  cause. 
In  some  cases  the  disease  begins  with  head  symptoms  of  an 
inflammatory  nature  in  the  midst  of  apparently  good  health. 
In  these  cases  it  may  be  presumed  that  cheesy  foci  exist  in 
some  part  of  the  body  in  a  latent  condition,  and  that  the 
vessels  of  the  pia  mater  become  rapidly  and  suddenly  invaded 
at  the  time  of  the  outbreak  of  acute  symptoms. 

Premonitory  symptoms  may  also  be  absent  when  the  mem- 
branes of  the  brain  become  secondarily  affected  in  persons  who 
are  already  suffering  from  acute  general  tuberculosis,  or  from 
local  tuberculosis  of  the  lungs,  peritoneum,  or  other  organ. 
Under  these  circumstances  the  patient  may  have  been  sleep- 
less, restless,  feverish,  or  delirious,  before  the  pia  mater  is  impli- 
cated, so  that  the  brain  symptoms  make  their  appearance 
without  any  warning.  The  first  symptoms  which  indicate  an 
affection  of  the  pia  mater  in  these  cases  may  be  violent 
headache,  vomiting,  or  facial  paralysis,  followed  quickly  by 
unconsciousness. 

As  the  invasion  approaches,  all  the  premonitory  symptoms, 
when  present,  become  more  pronounced.  Some  cases  are  ushered 
in  by  a  chill,  accompanied  by  a  rapid  rise  of  temperature,  while  in 
others  there  are  distinct  shiverings,  violent  headache,  attacks  of 
giddiness  and  vomiting.  The  disease  itself  presents  (a)  an 
initial  period  in  which  the  symptoms  may  be  referred  to  exci- 
tation of  the  cortex ;  (6)  a  period  in  which  symptoms  caused 
by  excitation  are  mixed  with  those  due  to  progressive  pressure 
caused  by  effusion  and  to  lesions  at  the  base  of  the  brain ; 
and  (c)  a  final  period  in  which  symptoms  due  to  pressure  caused 
by  the  ventricular  effusion  greatly  predominate. 


756  DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN. 

(ct)  The  Period  of  Invasion. — Vomiting  is  the  most  common 
special  symptom  of  the  period  of  invasion.  It  varies  greatly 
in  frequency,  but  as  a  rule  occurs  only  twice  in  twenty-four 
hours  during  the  first  two  or  three  days  of  the  disease.  In 
some  few  cases,  however,  the  child  vomits  incessantly,  whether 
food  is  taken  or  not.  When  once  the  tendency  to  vomit  has 
ceased  for  twenty-four  hours  it  does  not  ordinarily  recur.  Con- 
stipation is  present  as  a  rule  throughout  the  whole  course  of  the 
disease.  Although  there  are  occasional  exceptions  the  consti- 
pation is  not  often  obstinate,  and  it  is  generally  easy  to  pro- 
cure action  of  the  bowels  by  ordinary  means. 

Headache  is  another  important  symptom  of  the  first  stage  of 
the  disease,  and  may  be  of  a  dull,  heavy,  or  lancinating 
character.  The  headache,  although  continuous,  is  subject  to 
paroxysmal  exacerbations.  It  is  sometimes  referred  to  the  sum- 
mit of  the  frontal  bone,  but  more  frequently  the  whole  head  is  the 
seat  of  pain.  Headache  is  usually  an  urgent  symptom  while 
consciousness  is  retained,  and  its  temporary  exacerbations  are 
made  known  by  moaning  or  shrieks;  while  even  after  uncon- 
sciousness has  set  in  the  patient  puts  his  hand  to  his  head, 
wrinkles  his  forehead,  and  distorts  his  face  as  if  from  pain. 
Vertigo  is  always  present.  Patients  feel  as  if  they  were  falling 
in  bed,  or  as  if  surrounding  objects  were  revolving  round  them, 
and  the  gait  is  often  reeling  and  unsteady;  but  the  rapid  de- 
velopment of  severe  symptoms  soon  prevents  all  attempts  at 
station  and  locomotion. 

Motor  disturbances  are  almost  always  present  in  this  stage 
of  the  affection.  Spasmodic  movements  occur  in  the  form  of 
partial  corivulsions,  giving  rise  to  tremor  and  conjugate  devia- 
tion of  the  eyeballs,  strong  convergent  and  divergent  squints, 
grinning  contortions  of  the  muscles  of  the  face,  grinding  of  the 
teeth,  and  rotation  of  the  head  and  neck.  In  children  epilepti- 
form convulsions  are  not  uncommon,  but  they  are  rare  in  adults. 
It  is  very  probable  that  what  Trousseau  has  described  as  the 
hydrocephalic  cry,  which  so  commonly  occurs  during  this  period 
of  the  disease,  is  due  to  spasmodic  action  of  the  respiratory 
and  laryngeal  muscles,  and  is  quite  independent  of  conscious- 
ness. "It  is  a  single,  violent  cry,"  says  Trousseau,  "resembling 
the  cry  of  a  person  suddenly  exposed  to  great  danger;  the 


DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN.  757 

expression  of  the  face  is  not  that  of  suffering.  Any  period  of 
the  disease  may  be  attended  by  this  cry,  which  may  occur  every 
hour,  half-hour,  or  even  every  five  minutes."  Besides  spasmodic 
movements,  spastic  rigidity  of  one  or  more  groups  of  muscles 
may  occur,  the  most  important  of  these  being  stiffness  of  the 
muscles  of  the  nape  of  the  neck  and  back,  and  retraction  of 
the  abdominal  muscles.  Slight  paralysis  of  some  of  the  facial 
and  ocular  muscles  may  occur,  consisting  of  inequality  in  the 
pupils,  ptosis,  strabismus,  or  slight  facial  paralysis. 

Sensory  disturbances  are  not  so  well  marked,  and  they  are 
usually  soon  obscured  by  loss  of  consciousness.  At  times  a 
general  hypersesthesia  of  the  whole  surface  of  the  body  may  be 
observed  at  the  beginning  of  the  disease,  while  at  other  times 
this  condition  may  be  limited.  General  or  partial  ansesthesia 
is  not  an  unfrequent  symptom  at  an  advanced  period  of  the 
disease,  and  it  has  occasionally  been  observed  as  a  premonitory 
symptom  (Dreyfous).  Intolerance  of  sound  and  light  is  a  pro- 
minent symptom  :  the  child  is  impatient  of  the  slightest  noise, 
and  avoids  the  light  by  lying  with  the  face  buried  in  the 
pillow  or  turned  towards  the  wall,  keeping  the  eyelids  firmly 
closed.  In  this,  the  usual  attitude  of  the  first  period  of  the 
disease,  the  knees  are  drawn  up  towards  the  abdomen,  and 
Dreyfous  believes  that  it  is  not  voluntarily  assumed  in  order  to 
avoid  the  light,  but  corresponds  to  the  forced  attitudes  of 
animals  arising  from  experimental  injury  of  the  brain. 

Psychical  disturbances  are  not  always  present  in  the  early 
period  of  the  affection.  The  patient  cannot,  however,  form 
consecutive  trains  of  ideas,  and  children  soon  become  somnolent, 
lie  with  their  eyes  closed,  and  reply  to  questions  curtly  or 
merely  by  a  nod.  When  raised  up,  they  complain  much,  knit 
their  brows,  throw  back  their  heads,  and  slip  down  in  bed;  they 
cannot  bear  the  slightest  disturbance,  and  will  clench  their 
teeth  against  food.  Delirium  is  of  frequent  occurrence  when 
the  patient  is  half  asleep;  and,  in  the  case  of  children,  the 
hydrocephalic  cry  is  not  unfrequently  heard  at  this  time,  being 
accompanied  by  starting  up  in  terror.  At  other  times  the 
patient  may  spring  from  bed,  or  make  defensive  movements, 
in  consequence  of  hallucinations  of  sight  and  of  hearing.  The 
somnolence  soon  increases,  the  eyes  stare  without  expression 


758  DISEASES   OF  THE  MEMBRANES   OF  THE   BRAIN. 

into  vacancy,  and  the  patient  ceases  to  speak  to  his  attendants ; 
but  he  talks  senselessly  with  himself,  or  laughs,  sings,  whistles, 
or  shouts,  and  performs  meaningless  movements,  such  as  pluck- 
ing at  imaginary  objects,  picking  the  bed-clothes,  blowing, 
spitting,  and  grimacing.  After  a  time  these  disturbances  cease, 
and  the  mental  faculties  may  again  become  completely  or 
partially  clear;  but  after  a  longer  or  shorter  period,  new  and 
more  profound  disturbances  supervene,  which  increase  until  the 
fatal  termination. 

Examination  of  the  retina  may  throw  light  on  the  nature 
of  the  affection.  When  general  miliary  tuberculosis  exists 
tubercles  of  the  choroid  are  frequently  found,  but  they  are 
absent  in  tuberculosis  a,ffecting  the  pia  mater  alone.  Marked 
stasis  is  often  found  even  at  this  early  period  in  the  veins  of 
the  disc.  So  long  as  the  patients  are  tolerably  conscious 
derangement  of  vision  is  generally  absent. 

The  pulse  is,  as  a  rule,  slow  and  full  (from  60 — 70  beats  per 
minute)  during  the  early  stage  of  the  affection,  but  it  is  subject 
to  rapid  variations  during  muscular  exertion  of  every  kind  and 
psychical  excitement,  especially  in  the  case  of  children.  The 
pulse  is  often  decidedly  irregular  even  at  this  stage  of  the 
disease.  The  temperature  is  very  inconstant,  and  does  not 
conform  to  any  type. 

The  skin  is  usually  dry,  and  even  in  those  cases  where  the 
tubercular  meningitis  is  associated  with  phthisis  the  sweats  of 
the  latter  disease  usually  cease  when  the  meningitis  manifests 
itself.  It  has  also  been  observed  that  the  cough,  dyspnoea, 
and  expectoration  of  phthisis  cease,  and  in  the  case  of  intestinal 
tuberculosis  the  diarrhoea  is  arrested.  The  injection  of  the 
face  and  conjunctivae  varies  frequently  without  obvious  cause ; 
lividity  of  the  face  belongs  to  a  later  period  or  is  dependent  on 
lung  complications. 

The  average  duration  of  the  first  stage  is  about  eight  days, 
but  it  varies  from  two  days  to  two  or  three  weeks,  and  is  not 
unfrequently  followed  by  a  remission  which  leads  the  friends  of 
the  patient  to  hope  for  a  favourable  termination. 

(6)  The  second  stage  is  now  ushered  in  with  the  evidences  of 
loss  of  functional  activity.  The  signs  of  excitement  become  less 
frequent,  and  somnolence  and  mental  torpor  more  prominent. 


DISEASES   OF   THE   MEMBRANES   OF  THE   BRAIN.         759 

At  times  a  profound  coma.is  rapidly  developed,  which  in  children 
is  frequently  ushered  in  by  a  convulsion,  and  which  generally 
continues  unbroken  until  the  fatal  termination,  but  in  some 
cases  there  are  short  clear  intervals.  The  hydrocephalic  cry  in 
the  case  of  children  is  most  frequent  at  this  time,  and  adults 
in  the  midst  of  sopor  give  evidence  of  severe  headache  by 
groans  and  gestures. 

Spasmodic  movements  and  muscular  rigidity  are  more  fre- 
quent than  in  the  first  stage.  Contractions  of  the  ocular 
muscles  give  rise  to  combined  movements  of  the  eyeballs 
(nystagmus)  and  inequality  of  the  pupils,  while  slight  con- 
vulsive movements  occur  in  the  facial  muscles  and  in  those 
of  the  extremities.  The  automatic  movements  of  chewing, 
winking,  whistling,  or  grinding  of  the  teeth  are  also  frequent ; 
while  tremors  of  the  extremities  or  of  the  whole  body  often 
occur.  A  case  is  recorded  by  Dr.  Hughlings-Jackson  in  which 
the  movements  of  the  extremities  and  face  corresponded  exactly 
to  those  of  acute  chorea.  At  other  times  the  muscles  are  main- 
tained in  a  state  of  cataleptic  rigidity,  and  the  extremities  may 
then  assume  various  forced  attitudes. 

The  stiffness  of  the  muscles  of  the  nape  of  the  neck  becomes 
more  intense,  so  that  the  head  is  drawn  back  and  thrust  into 
the  pillow.  The  rigidity  may  also  extend  to  the  muscles  of  the 
trunk,  so  that  the  body  is  maintained  in  a  condition  of  tetanic 
rigidity,  the  opisthotonos  either  appearing  in  paroxysms  and 
lasting  only  a  few  minutes  at  a  time,  or  remaining  continuous 
until  death.  Paralyses  of  various  extent  and  distribution  now 
make  their  appearance.  Paralysis  of  the  oculo-motor  nerve  is 
common,  and  gives  rise  to  divergent  squint,  ptosis,  dilatation, 
and  fixity  of  one  pupil.  The  trochlear  nerve  may  be  paralysed 
along  with  the  third,  but  is  never  affected  alone.  Paralysis  of 
the  abducens  may,  however,  occur  as  a  separate  affection.  The 
paralytic  form  of  conjugate  deviation  of  the  eyes  and  rotation  of 
the  head  and  neck  may  appear  at  this  period  of  the  disease. 

Facial  paralysis  is  manifested  by  the  usual  signs  of  paralysis 
of  cerebral  origin.  In  some  cases  total  paralysis  of  the  facial 
has  been  observed,  and  in  these  the  affection  is  due  to  inter- 
ference with  the  nerve  by  effusion  at  the  base  of  the  brain. 
In  other  cases  the  ocular  and  frontal  branches  were  affected, 


760  DISEASES   OF  THE  MEMBRANES   OF   THE   BRAIN. 

while  the  oral  and  nasal  branches  were  spared,  and  in  these, 
cases  it  is  doubtful  whether  the  symptoms  are  to  be  attributed 
to  cortical  injury  or  to  partial  pressure  on  the  nerve  at  the  base 
of  the  brain. 

Paralysis  of  the  hypoglossal  nerve  is  manifested  by  the 
tongue  turning  towards  the  paralysed  side  on  protrusion,  but 
this  nerve  is  not  so  frequently  affected  as  the  facial.  Hemi- 
plegia and  hemiparesis  are  rare,  but  monoplegia  are  frequent. 
At  times  one  arm  or  one  leg  is  paretic  or  completely  paralysed ; 
while  occasionally  the  paralysis  assumes  the  paraplegic  form, 
or  a  considerable  diminution  of  strength  may  occur  in  all  four 
extremities. 

Sensory  paralysis  also  supervenes  at  this  stage  of  the 
affection.  At  times  there  is  a  general  diminution  of  all 
forms  of  cutaneous  sensibility,  at  other  times  anaesthesia  may 
be  limited  to  one  or  other  extremity,  or  to  the  region  of  distribu- 
tion of  one  of  the  branches  of  the  trigeminus.  After  a  time 
every  form  of  sensibility  is  much  weakened  or  abolished. 

The  retinae  undergo  decided  changes  in  this  stage  of  the 
affection.  The  veins  are  dilated  and  stand  out  distinctly  on  the 
swelled  papilla.  Extravasations  of  blood  occasionally  occur  in 
the  retina,  but  they  are  usually  slight  in  extent.  Symptoms 
of  neuro-retinitis  appear  either  along  with  the  phenomena  of 
stasis  or  apart  from  them. 

Vomiting  may  occur  occasionally  in  this  stage,  constipation 
continues,  the  urine  is  generally  passed  in  bed  or  there  is  com- 
plete retention. 

The  pulse  becomes  less  frequent,  and  may  sink  to  60  or  still 
lower,  and  is  at  the  same  time  fuller ;  but  the  slightest  excite- 
ment may  raise  the  number  of  beats  over  100  per  minute,  and 
it  is  apt  to  become  irregular.     The  temperature  varies. 

The  respiration  is  sometimes  normal,  at  other  times  irre- 
gular, occasionally  assuming  the  character  of  the  Cheyne-Stokes 
respiration.  Neuro-paralytic  oedema  of  the  lungs  is  liable  to 
occur,  at  this  period  of  the  disease.  This  period  may  last  about 
a  week,  and  then  the  third  stage  of  the  disease  is  ushered 
in  by  the  appearance  of  persistent  coma. 

The  Third  Stage. — The  patient  is  now  completely  insensible 
to  most  external  excitants,  although  he  may  still  respond  to  a 


DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN.  761 

loud  voice  close  to  the  ear,  and  most  reflex  actions  are  extin- 
guished. 

Isolated  paralyses  are  not  so  readily  observed,  as  there  is 
general  relaxation  of  the  whole  muscular  system.  Rigidity  of 
the  masticatory  muscles  and  of  the  muscles  of  the  back  and 
extremities  is  not  unfrequently  observed.  Convulsions  are  rare 
in  adults;  but  in  children  partial  convulsive  spasms  still  occur, 
and  immediately  before  death  the  patient  may  be  seized  with 
general  convulsions.  The  electric  excitability  of  the  muscles  to 
both  constant  and  induction  currents  is  normal.  Every  form  of 
sensibility  is  now  completely  abolished.  The  pupils  are  dilated 
and  fixed, the  upper  lids  fall  inert  and  paralysed  over  the  eyeballs, 
and  an  ophthalmoscopic  examination  reveals  signs  of  marked 
stasis  and  oedema  of  the  optic  discs,  with  neuro-retinitis.  In 
the  case  of  young  children,  the  pulsations  of  the  fontanelle 
become  weaker  and  weaker,  and  may  disappear  before  death. 

The  pulse  during  this  period  becomes  more  and  more  fre- 
quent and  may  be  irregular. 

The  respiration  is  irregular,  and  at  times  so  superficial  and 
feeble  that  it  may  escape  observation,  while  at  other  times  it  is 
forced  and  deep.  Rapid  emaciation  occurs,  especially  in  the 
case  of  children ;  the  skin  is  generally  dry  and  rough,  and  may 
become  slightly  livid  with  the  decreasing  force  of  the  heart ; 
occasionally  a  bed-sore  appears.  The  temperature  during  this 
period  varies  greatly.  In  some  cases  it  is  below  normal,  and 
immediately  before  death  may  sink  as  low  as  95° F.  or  even  93° F. 
In  another  series  of  cases  a  state  of  moderate  fever  continues 
up  to  the  time  of  death;  while  in  a  third  group  the  fever 
greatly  increases  before  death,  and  may  even  continue  to  in- 
crease for  some  time  afterwards. 

The  urine  is  generally  scanty,  with  high  specific  gravity  ;  its 
quantity  may  be  increased,  normal,  or  diminished ;  the  propor- 
tion of  chlorides  varies  greatly,  and  the  phosphates  are  said 
to  be  increased.  A  small  quantity  of  albumen  is  frequently 
present,  but  sugar  is  rare.  The  duration  of  the  paralytic  stage 
is  generally  three  or  four  days,  and  seldom  reaches  a  week. 

§  841.  Course,  Duration,  and  Terminations. — The  course 
of  tubercular  meningitis  varies  greatly.    It  has  already  been 


762  DISEASES   OF   THE   MEMBRANES   OF  THE  BRAIN. 

mentioned  that  when  the  affection  of  the  pia  mater  is  secondary 
to  phthisis  or  tubercular  peritonitis  the  disease  begins  without 
any  premonitory  symptoms,  and  the  symptoms  of  the  first  stage 
are  obscure  or  entirely  wanting.  Old  affections  of  the  brain, 
such  as  tubercular  tumours,  also  render  the  course  of  the  disease 
variable.  Under  the  latter  circumstances  tubercular  meningitis 
is  superadded  to  a  long-existing  affection  of  the  brain  as  a 
terminal  phenomenon,  and  it  is  then  difi&cult  to  diagnosticate 
anything  beyond  a  meningitis  of  unknown  cause. 

In  other  cases  tubercular  meningitis  runs  a  rapid  course,  and 
may  terminate  in  five  or  six  days.  In  some  of  these  cases  ven- 
tricular effusion  is  wanting,  and  death  is  due  to  some  acute 
process  in  the  brain  itself.  Some  cases,  on  the  other  hand, 
have  an  exceedingly  protracted  course ;  the  invasion  is  slow 
and  insidious,  the  symptoms  are  gradually  developed,  and  the 
disease  may  last  from  thirty  to  fifty  or  even  sixty  days. 

In  all  cases  in  which  the  disease  began  by  sudden  paralysis, 
or  paralysis  combined  with  aphasia,  the  miliary  tubercles  have 
been  found  limited  to  the  area  of  distribution  of  the  Sylvian 
artery,  while  the  choroid  plexuses  have  been  free  from  tubercles, 
and  great  effusion  absent. 

The  disease  is  ushered  in  by  depression  of  spirits,  anxiety, 
anguish,  hallucinations  of  hearing,  self-accusations,  and  attempts 
at  escape  from  punishment.  After  about  forty-eight  hours, 
unconsciousness  supervenes,  ptosis  and  facial  paralysis  soon 
follow  with  all  the  other  signs  of  tubercular  meningitis. 

Sometimes  the  course  of  the  disease  is  very  similar  to  that 
of  typhoid  fever.  In  other  cases,  especially  in  children,  un- 
consciousness comes  on  at  an  early  period  of  the  disease,  and 
constitutes  throughout  the  most  prominent  symptom  of  the 
affection.  In  these  cases  large  ventricular  effusion  is  found 
after  death,  and  the  brain  has  been  doubtless  subjected  to 
pressure  at  an  early  period. 

Some  cases  are  recorded  in  which  every  time  the  patient 
attempted  to  sit  up  attacks  of  tetanic  rigidity  supervened 
(Biermer,  Gerhardt). 

§  842.  Morbid  Anatomy. — The  morbid  anatomy  of  tuber- 
cular meningitis  varies  with  respect  both  to  the  appearances 


DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN.  763 

found  in  the  brain  itself  and  to  morbid  changes  found  in 
other  organs.  Various  changes  may  be  found  in  the  cranial 
bones,  and  caries  of  the  petrous  portion  of  the  temporal  bone 
is  frequently  the  primary  cause  of  the  disease.  On  removing 
the  calvaria  tubercles  may  be  found  in  the  dura  mater,  and 
would  probably  be  found  more  frequently  if  a  careful  search 
were  made.  They  are  sometimes  found  between  the  two  layers 
close  to  small  branches  of  the  middle  meningeal  artery,  while 
others  appear  to  be  situated  in  the  inner  lamella  of  the  dura 
mater  (Huguenin). 

The  changes  in  the  pia  mater  are,  (a)  those  which  are 
directly  connected  with  the  formation  of  miliary  tubercles, 
(&)  those  caused  by  the  inflammation  surrounding  them,  and  (c) 
those  which  arise  from  the  effusion  into  the  ventricles. 

(a)  The  pia  mater  is  studded  with  miliary  tubercles.  They 
appear  as  greyish-white  granulations,  varying  from  a  size  scarcely 
visible  to  that  of  a  millet  seed,  while  masses  as  large  as  a  pea 
may  be  produced  by  aggregation. 

The  tubercles  are  always  distributed  in  the  neighbourhood  of 
vessels.  In  some  cases  the  whole  length  of  an  artery  from  its 
origin  in  the  circle  of  Willis  is  covered  with  numerous  tubercles, 
while  in  rare  cases  the  granulations  are  chiefly  situated  on  the 
peripheral  branches  of  the  vessels.  At  times  all  the  arteries 
given  off  from  the  circle  of  Willis  are  studded  with  tubercles, 
while  at  other  times  particular  portions  of  the  surface  of  the 
brain  are  either  exclusively  affected  or  affected  to  a  much  greater 
extent  than  the  remaining  portions. 

The  territory  supplied  by  the  Sylvian  arteries  is  particularly 
liable  to  be  affected,  and  tubercles  are  also  commonly  found  at 
the  bottom  of  the  great  longitudinal  fissure  along  the  vessels 
which  supply  the  corpus  callosum.  At  other  times  the  tubercles 
are  most  abundant  in  the  pia  mater  covering  the  upper  and 
under  surfaces  of  the  cerebellum,  or  on  the  median  surfaces  and 
posterior  lobes  of  the  cerebral  hemispheres. 

The  number  of  tubercles  present  varies  greatly.  At  times 
they  may  be  so  limited  that  a  careful  search  is  necessary  to  find 
them,  while  in  other  cases  they  are  numbered  by  thousands. 
The  granulations  may  be  isolated,  or  collected  in  dense  groups ; 
while  occasionally   they   form,    along   with    the   inflammatory 


764  DISEASES    OF   THE   MEMBEANES   OF   THE   BRAIN. 

products  of  the  pia  mater,  thick  masses  which  exert  pressure 
on  the  brain. 

The  tubercles  are  found  in  all  stages  of  development.  At 
times  all  of  them  consist  of  the  small,  grey,  miliary  granula- 
tions, but  at  other  times  these  are  mixed  with  larger  tubercles, 
which  are  yellow  at  their  centres  from  fatty  degeneration. 
Callosities  mainly  composed  of  connective  tissue  and  enclosing 
old  tubercles  are  found  on  various  parts  on  the  surface  of  the 
brain. 

(6)  The  inflammatory  changes  in  the  pia  mater  may  or  may 
not  be  well  marked,  according  to  circumstances.  When  the 
pressure  caused  by  the  effusion  has  been  great,  the  surface  of 
the  pia  mater  may  be  dry  and  its  vessels  empty.  The  convo- 
lutions are  flattened  and  the  sulci  more  or  less  narrowed.  A 
moderate  hypersemia  of  the  pia  mater  is,  however,  frequently 
present,  especially  at  the  base,  where  the  vessels  are  less  liable 
to  be  subjected  to  pressure. 

Evidences  of  suppuration  are  generally  found  at  the  base 
of  the  brain.  Under  these  circumstances  the  whole  tissue  is 
swollen  and  yellowish,  and  cloudy  streaks  of  exudation  may 
be  observed  passing  along  the  vessels.  The  convexity  is  not 
so  liable  to  be  the  seat  of  suppuration.  In  some  cases,  however, 
a  sero-purulent  effusion  is  observed  in  the  pia  mater  of  the  con- 
vexity, while  at  other  times  the  evidences  of  suppuration  on  the 
convexity  are  still  better  marked.  In  the  latter  case  the  pia  has 
lost  its  delicacy  and  transparency,  is  inelastic  and  easily  torn, 
and  is  everywhere  infiltrated  with  a  sero-fibrinous,  yellowish 
exudation. 

The  exudation  often  extends  backwards  over  the  anterior 
surface  of  the  pons  and  medulla  oblongata,  creeps  upwards  to 
the  upper  surface  of  the  medulla,  and  implicates  the  pia  of  the 
entire  cerebellum.  The  suppurative  process  may  extend  froni 
the  chiasma  forwards  to  the  under  and  internal  surfaces  of  the 
anterior  lobe,  along  the  olfactory  lobe  and  the  artery  of  the 
corpus  callosum. 

The  changes  are  not  always  symmetrical,  but  in  general  it 
may  be  said  that  the  greatest  suppuration  will  be  found  where 
the  tubercles  are  most  numerous. 

The  inflammation  may  extend  along  the  processes  of  pia  mater 


DISEASES   OF   THE   MEMBRANES   OF   THE  BRAIN.  765 

which  enter  the  descending  cornua  of  the  lateral  ventricles,  and 
may  also  be  transmitted  through  the  great  transverse  fissure 
to  the  velum  interpositum.  At  times  the  choroid  plexuses  and 
velum  interpositum  may  be  covered  with  a  yellowish  purulent 
exudation. 

Extravasations  of  blood,  varying  in  size  from  minute  specks 
to  a  patch  an  inch  or  more  in  diameter,  may  be  found  in  the 
meshes  of  the  pia  mater.  The  growth  of  tubercle  in  the  walls 
of  a  vessel  presses  upon  the  media  and  intima,  and  thus  dimi- 
nishes its  lumen.  The  vessel  is  thus  partially  obstructed,  and 
either  a  thrombus  may  form  at  this  point,  followed  by  softening 
of  the  coats  of  the  vessel  and  extravasation,  or  the  internal 
and  middle  coats  of  the  vessel  are  perforated  directly  by  the 
tubercle. 

(c)  The  ventricles  are  generally  distended  with  serous  fluid, 
but  effusion  is  absent  in  about  20  per  cent  of  all  cases.  The 
septum  lucidura  is  frequently  broken  down ;  while  the  third 
ventricle  is  distended,  but  to  a  less  degree  than  the  lateral 
ventricles,  owing  to  the  resistance  offered  by  the  optic  thalami. 
The  soft  commissure  is  generally  more  or  less  torn  and  speckled 
with  capillary  haemorrhages,  and  the  anterior  portion  of  the 
ventricle  may  be  so  distended  that  the  pia  mater  covering  the^ 
lamina  cinerea  is  exposed.  The  aqueduct  of  Sylvius  is  fre- 
quently dilated  and  the  fourth  ventricle  distended.  The  fluid 
is  at  times  purely  serous,  while  at  other  times  it  is  cloudy 
from  the  presence  of  epithelial  cells  and  white  blood  cor- 
puscles, and  purulent  effusions  are  occasionally  observed.  In 
^SGiloe  cases  the  fluid  is  tinged  with  blood  derived  from  rup- 
ture of  small  vessels  in  the  choroid  plexuses.  The  choroid 
plexuses  are  hypersemic,  and  miliary  tubercles  may  be  found  in 
them,  though  never  in  large  numbers  ;  small  extravasations 
of  blood  are  not  uncommon.  The  ependyma  of  the  ventricles 
is  sometimes  dense  and  opaque,  and  when  viewed  by  a  side 
light  its  surface  looks  as  if  sprinkled  with  fine  dust.  At  other 
times  larger  granulations  may  be  observed  intermediate  in  size 
between  the  fine  dust  and  miliary  tubercles. 

The  distribution  of  tubercles,  inflammatory  changes,  and 
effusion  may  be  combined  in  various  ways.  In  the  majority  of 
cases  miliary  tubercles  are  distributed  over  the  entire  pia  mater 


766  DISEASES   OF  THE  MEMBRANES   OF   THE  BRAIN. 

and  choroid  plexuses,  there  is  a  large  ventricular  effusion,  and 
the  base  of  the  brain  is  often  covered  by  a  purulent  exudation, 
which  in  some  cases  extends  to  the  convexity  of  the  hemi- 
spheres. In  a  few  cases  miliary  tubercles  are  scattered  in 
small  numbers  over  the  pia  mater,  the  choroid  plexuses  are  un- 
affected, ventricular  effusion  is  absent,  and  no  pus  is  visible  to 
the  naked  eye  either  over  the  base  or  convexity  of  the  brain. 
In  other  cases  the  tubercles  are  limited  to  the  region  of  dis- 
tribution of  one  or  more  of  the  arteries  of  the  brain,  the  terri- 
tories of  the  Sylvian  arteries  being  specially  liable  to  be 
affected.  The  base  of  the  brain  and  the  vascular  region  in 
which  the  tubercles  are  developed  are  covered  by  a  purulent 
exudation,  and  there  is  a  moderate  ventricular  effusion.  In 
some  cases  the  evidences  of  recent  tuberculosis  are  accom- 
panied by  circumscribed  thickenings  and  laminae  of  caseous 
connective  tissue,  in  which  old  miliary  and  caseous  tubercles 
are  embedded. 

The  brain  itself  undergoes  many  important  changes.  If  the 
effusion  be  large  the  cortex  and  neighbouring  white  substance 
are  dry  and  anaemic,  but  when  effusion  is  absent  these  parts  are 
congested  and  oedematous.  The  cortex  is  often  studded  -  by 
^punctiform  haemorrhages,  caused,  according  to  Hindfleisch,  by 
tubercular  degeneration  of  the  nutritive  arteries.  The  vessels 
of  the  cortex  are  surrounded  by  clusters  of  white  and  red 
blood  corpuscles.  When  the  pia  mater  is  stripped  off,  portions" 
of  the  substance  of  the  brain  will  be  found  clinging  to  the 
vessels  of  the  cortex,  and  consequently  the  surface  of  the  brain 
assumes  a  rough  appearance.  White  softening  of  the  substance 
of  the  hemispheres  is  often  observed.  It  may  involve  portions 
only  of  the  fornix  and  corpus  callosum,  or  may  extend  into  the 
centrum  ovale  and  basal  ganglia. 

The  cranial  nerves  may  all  be  affected  in  greater  or  less 
degree  in  tubercular  meningitis.  The  inflammatory  process  set 
up  at  the  base  of  the  brain  may  extend  to  the  sheaths  of  the 
nerves  and  gives  rise  to  neuritis,  and  when  effusion  takes  place 
they  are  injuriously  affected  by  pressure. 

The  spinal  cord  is  not  unfrequently  affected  in  tubercular 
meningitis.  The  inflammatory  affection  of  the  pia  mater  passes 
down  a  varying  distance  into  the  spinal  canal,  and  tubercles 


DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN.  767 

are  found  in  the  spinal  pia  mater.  Tuberculosis  of  the  lungs, 
pleurae,  pericardium,  peritoneum,  liver,  spleen,  lymphatic  glands, 
and  kidneys  is  frequently  associated  with  the  affection  of  the 
cerebral  membranes.  Cheesy  degeneration  of  the  mesenteric  or 
retro-peritoneal  glands,  or  of  the  bronchial,  cervical,  or  axillary 
glands,  is  almost  always  found  associated  with  the  cerebral 
affection.  Suppurations  of  the  vertebrae,  of  the  bones  of  the 
extremities,  and  pelvis,  affections  of  the  periosteum  and 
joints,  caries  of  the  nasal  bones  from  syphilis,  caries  of  the 
clavicle,  sternum,  and  petrous  portion  of  the  temporal  bone  are 
some  of  the  most  frequent  causes  of  tubercular  meningitis. 

§  843.  Morbid  Physiology. — Miliary  tubercles  act  as  foreign 
bodies  and  produce  an  attack  of  meningitis.  In  the  early  stage  of 
inflammation  the  symptoms  are  mainly  those  of  irritation  of  the 
cortex.  It  is  manifest  that  the  initial  symptoms  of  the  disease 
must  largely  depend  upon  the  distribution  of  the  tubercles 
and  resulting  inflammation.  If  the  tubercular  infiltration  be 
mainly  limited  to  one  or  more  of  the  Sylvian  arteries,  the  disease 
will  be  ushered  in  by  symptoms  of  motor  irritation,  such  as  slight 
spasms,  unilateral,  or  even  general  convulsions.  In  those  cases 
which  begin  with  aphasia  the  lesion  is  situated,  as  a  rule,  along 
the  left  Sylvian  artery,  the  branch  which  supplies  the  posterior 
end  of  the  third  frontal  convolution  being  specially  implicated. 
In  the  recorded  cases  it  is  not  mentioned  whether  the  loss  of 
speech  was  preceded  by  any  evidence  of  irritation  of  Broca's 
\^onvolutiou.  Difficulties  in  the  articulation  of  words  may  occur 
when  there  is  no  aphasia.  When  the  area  of  distribution  of 
the  posterior  cerebral  artery  is  chiefly  affected,  the  .  initial 
symptoms  will  be  sensory  disturbances,  as  hallucinations  of 
sight  and  hearing ;  while  the  motor  disorders  consist  of  asso- 
ciated movements,  as  those  of  defence  against  threatened  blows, 
or  attempts  at  escape  from  apprehended  punishment.  When 
the  anterior  cerebral  arteries  are  mainly  affected,  the  disease 
begins  by  sopor  alternating  with  slight  delirious  excitement, 
and  coma  usually  supervenes  at  an  early  period. 

When  the  cerebellar  arteries  are  affected,  stiffness  of  the 
muscles  of  the  nape  of  the  neck  and  back,  and  tetanic  seizures 
are  prominent  symptoms.     The  various  irregularities  of  gait 


768  DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN. 

which  are  observed  during  the  first  stage  of  the  affection  may 
often  be  explained  by  reference  to  implication  of  the  cerebellum. 
Dreyfous  attributes  great  importance  to  implication  of  the  pons 
varolii  in  the  production  of  forced  attitudes  and  various  sensory 
disturbances,  but  it  does  not  appear  to  me  that  his  reasoning  is 
conclusive. 

Motor  paralysis  occurs  mainly  in  the  second  stage,  but  is 
also  observed  at  an  earlier  period.  In  the  first  stage  the  para- 
lyses are  probably  caused  by  irritation  and  subsequent  ex- 
haustion of  a  motor  centre,  but  in  the  second  stage  they  are 
caused  by  destructive  changes  in  the  motor  area  of  the  cortex. 
Peripheral  paralysis  may  be  produced  by  the  cranial  nerves 
becoming  implicated  in  the  exudation  as  they  pass  along  the 
base  of  the  brain.  The  sensory  portion  of  the  fifth  and  the 
nerves  of  special  sense  as  well  as  the  motor  nerves  may  be 
injured  by  the  exudation. 

The  final  stage  of  general  paralysis  of  sensory  and  motor 
functions  is  explained  by  the  gradual  compression  of  the  brain, 
due  to  increasing  ventricular  effusion. 

§  844.  Diagnosis. — Tubercular  meningitis  is  liable  to  be  mis- 
taken for  cerebro-spinal  meningitis,  simple  purulent  meningitis, 
hypersemia  of  the  brain,  the  terminal  stage  of  abscess,  tumours 
of  the  brain,  thrombosis  of  the  sinuses,  and  leptomeningitis 
infantum,  but  the  diagnosis  between  it  and  these  affections 
have  either  been  or  will  be  herafter  considered. 

Typhoid  fever  with  severe  brain  symptoms  may  closely 
simulate  tubercular  meningitis.  Difficulties  of  diagnosis  only 
arise  in  the  case  of  aberrant  forms  of  typhoid  fever  in  which  the 
bowels  are  confined  and  empty,  the  abdominal  muscles  retracted, 
and  the  spots  absent.  On  the  other  hand,  it  must  be  remem- 
bered that  diarrhoea  may  be  present  in  tubercular  meningitis, 
that  hgemorrhage  may  occur  from  the  bowels  in  cases  of  general 
tuberculosis,  and  that  a  roseolar  rash  may  appear  on  the  surface 
of  the  body. 

The  course  of  the  temperature  in  typhoid  fever  is  often 
variable,  and  not  always  to  be  relied  upon  as  a  means  of 
diagnosis.  The  diagnosis  must  be  made  from  a  consideration 
of  all  the  circumstances  of  the  case. 


DISEASES  OF  THE   MEMBRANES   OF  THE  BRAIN.  769 

Gastric  derangement  in  young  children  may  cause  symptoms 
almost  identical  with  those  of  the  earlier  periods  of  tubercular 
meningitis ;  but  the  diagnosis  is  soon  cleared  up  by  the  progress 
of  the  case. 

It  should  also  be  remembered  that  many  acute  diseases  are 
attended  by  cerebral  symptoms  closely  resembling  those  of  the 
onset  of  tubercular  meningitis. 

§  845.  Prognosis. — The  prognosis  is  in  every  instance  ex- 
ceedingly grave.  Many  presumed  instances  of  recovery  are 
recorded,  but  these  cases  are  probably  examples  of  leptome- 
ningitis infantum  or  other  affection,  and  not  genuine  tuber- 
culosis of  the  pia  mater. 

§  846.  Treatment. — Prophylactic  treatment  is  of  the  utmost 
importance,  since  the  prospects  of  recovery  are  so  unfavourable 
when  once  the  disease  is  established.  The  children  of  scrofulous 
parents  should  be  most  carefully  reared.  Mothers  of  strongly 
marked  tubercular  diathesis  should  not  suckle  their  children, 
and  this  applies  all  the  more  to  the  case  of  those  in  whom 
evidences  of  tubercular  or  scrofulous  diseases  are  already  ap- 
parent. The  children  should  be  sent  to  the  country,  fed  with 
good  milk,  and  the  greatest  care  taken  in  attending  to  the 
condition  of  the  digjestive  organs ;  the  slightest  diarrhoea  should 
receive  immediate  attention.  Change  of  climate  to  a  moun- 
tainous  district  or  to  the  seaside  is  sometimes  attended  by  the 
most  decided  benefit.  With  regard  to  medicines,  iron,  iodide  of 
iron,  and  cod  liver  oil  must  be  administered  according  to  the 
circumstances  of  the  case. 

The  children  should  also  be  specially  guarded  from  the 
infectious  diseases  to  which  they  are  liable ;  because  an  attack 
of  measles  or  whooping-cough,  or  indeed  any  acute  disease, 
is  apt  to  lead  to  irritation  of  the  glands  and  subsequent  cheesy 
degeneration,  and  the  degenerated  glands  in  their  turn  may  be 
the  source  of  tuberculosis. 

When  the  symptoms  of  meningitis  have  once  appeared,  the 
grave  nature  of  the  prognosis  should  not  prevent  the  attendant 
from  adopting  appropriate  treatment.  There  is  a  possibility 
in    most   cases   that   the  meningitis   may  not   be  tubercular, 

XX 


770  DISEASES   OF   THE   MEMBRANES   OF  THE  BRAIN, 

and  at  any  rate  attempts  should  be  made  to  allay  inflammatory 
action.  Local  blood-letting  often  relieves  the  severe  headache 
and  gives  at  least  temporary  relief.  The  head  should  be  shaved 
and  ice  applied  persistently.  I  have  never  seen  the  slightest 
good  result  from  counter  irritation,  and  its  use  should  be  aban- 
doned. Smart  purgatives  may  be  of  some  use  in  relieving 
symptoms,  and  senna  in  conjunction  with  sulphate  of  magnesia 
or  the  compound  jalap  powder  answers  the  purpose  well.  Pre- 
parations of  mercury  and  iodine,  and  a  large  number  of  specific 
remedies  have  been  used  in  the  treatment  of  the  affection,  but 
with  questionable  success. 

When  once  the  progress  of  the  case  has  rendered  the  diag- 
nosis of  tubercular  meningitis  undoubted,  the  less  energetic 
treatment  the  better.  During  the  second  and  third  stages  cold 
to  the  head  may  be  exchanged  for  warm  applications.  I  have 
seen  delirium  and  restlessness  much  diminished  by  the  use  of  a 
warm  fomentation  to  the  head,  and  one  great  aim  of  treatment 
is  to  soothe  the  sufferings  of  the  patient  as  much  as  possible. 
With  this  view,  when  there  is  jactitation,  delirium,  and  scream- 
ing, small  doses  of  opium  or  chloral  should  be  administered ; 
such  stimulants  as  ammonia  or  even  small  quantities  of  wine 
may  be  of  use. 

Chronic  Hydrocephalus. 

§  847.  Dejinition.^-Ghromc  hydrocephalus  consists  of  an 
abundant  serous  accumulation  within  the  cranium,  occupying 
the  general  ventricular  cavity.  A  chronic  accumulation  of  fluid 
into  the  sac  of  the  arachnoid  has  been  described  under  the 
name  of  external  hydrocephalus,  but  it  is  doubtful  whether  the 
condition  has  any  real  existence. 

§  848.  Etiology. — Chronic  intracranial  effusions  in  adult  life 
are  probably  always  the  result  of  intracranial  tumours,  or  of 
occlusion  of  one  or  both  of  the  lateral  sinuses,  or  prolonged 
venous  congestion;  wliile  in  old  age  it  may  be  compensatory  to 
the  cerebral  atrophy  occurring  after  haemorrhage  and  encepha- 
litis. These  conditions  have,  however,  been  already  sufficiently 
considered,  and  we  shall  here  deal  exclusively  with  the  chronic 
hydrocephalus  which  is  congenital  or  acquired  soon  after  birth. 


DISEASES   OF  THE   MEMBRANES   OF  THE   BRAIN.         771 

The  etiology  of  congenital  hydrocephalus  is  not  well  known; 
but  hereditary  predisposition  appears  to  exert  some  influence 
in  its  production,  for  more  than  one  child  may  be  affected  in 
the  same  family.  Congenital  syphilis  is  probably  the  most 
important  predisposing  cause,  and  it  is  possible  that  too  much 
importance  has  been  attributed  to  rickets  in  its  production.  Of 
the  exciting  causes  little  is  known.  Chronic  hydrocephalus  is 
sometimes  preceded  by  an  attack  resembling  acute  hydro- 
cephalus. 

§  849.  Symptoms. — Chronic  hydrocephalus  is  generally  con- 
genital, and  cerebral  symptoms,  such  as  daily  recurring  convul- 
sions, strabismus,  or  rolling  of  the  eyeballs,  are  apparent  from 
the  infant's  birth,  while  in  a  few  days  or  weeks  the  head  is 
observed  to  undergo  progressive  enlargement. 

Impairment  of  the  general  nutrition  is  one  of  the  first 
symptoms ;  the  child  may  seem  eager  for  food  and  suck  well, 
yet  it  loses  flesh  and  strength,  and  the  skin  hangs  in  loose  folds 
on  its  attenuated  limbs.  The  bowels  are  generally  constipated, 
or  diarrhoea  may  alternate  with  constipation,  and  the  evacua- 
tions are  always  unhealthy.  The  child  is  restless  and  may  be 
drowsy  during  the  day,  but  wakeful  and  fretful  during  the 
night.  The  fontanelles  and  sutures  are  now  unusually  open, 
^the-anterior  fontanelle  is  tense  and  pulsates  strongly,  and  the 
child  is  subject  to  paroxysms  of  restlessness,  during  which  there 
is  increased  heat  of  the  head. 

The  sutures  become  gradually  wider  with  the  increase  of 
effusion,  the  fontanelles  increase  in  size,  the  head  assumes  a 
globular  form,  and  the  physiognomy  of  the  child  soon  acquires 
the  characteristic  features  of  chronic  hydrocephalus.  As  the 
fluid  accumulates  within  the  cranium,  it  presses  equally  in  all 
directions,  and  the  cavity  of  the  skull  must  enlarge  in  the  direc- 
tion of  least  resistance.  According  to  West,  the  great  increase 
in  the  size  of  the  head  is  effected  chiefly  by  enlargement  of  the 
anterior  fontanelle  and  by  widening  of  the  sagittal  suture, 
these  being  the  points  which  are  the  last  to  be  ossified,  and  at 
which  the  bones  of  the  skull  are  less  firmly  fixed.  The  frontal 
bones  are  consequently  pushed  forwards,  rendering  the  forehead 
round  and  prominent,  the  parietal  bones  are  pressed  backwards 


772  DISEASES  OF  THE  MEMBRANES   OF  THE  BRAIN. 

and  outwards,  and  the  occipital  bone  downwards  and  backwards, 
sometimes  even  so  far  that  it  assumes  an  almost  horizontal 
position.  The  head  is,  as  a  rule,  globular  and  flat  at  the  top, 
although  it  occasionally  assumes  a  conical  form.  Its  size 
varies,  and  it  has  been  known  to  measure  two  or  even  three 
feet  in  circumference.  The  orbital  plates  of  the  frontal  bones 
are  pushed  from  the  horizontal  to  an  oblique  or  it  may  be 
almost  vertical  position,  and  thus  encroach  upon  the  cavities 
of  the  orbits.  The  eyeballs  are  consequently  pressed  forwards 
and  rendered  prominent;  they  are  at  the  same  time  rotated 
downwards,  so  that  the  white  sclerotica  appears  below  the 
upper  lids,  while  the  pupils  are  half  hidden  beneath  the  lower 
lids.  On  placing  the  hand  over  the  open  fontanelles  and 
sutures  they  are  felt  tense  and  fluctuating.  The  hair  grows 
scantily  over  the  head,  the  skin  is  tense  and  shining,  differing 
in  this  respect  from  the  wrinkled  condition  of  that  of  the  rest 
of  the  body,  distended  veins  are  seen  to  ramify  over  the 
scalp,  and  the  enlarged  head  offers  a  remarkable  contrast  to 
the  small  face,  which,  according  to  West,  retains  for  a  long 
time  its  infantile  dimensions.  The  child  has  a  dull  and  stupid 
expression ;  he  cannot  hold  his  head  up,  and  is  therefore 
obliged  to  maintain  the  recumbent  position  or  to  assume  a 
half-sitting  posture,  while  his  head  is  supported  by  his  hands 
or  propped  up  with  pillows.  The  cerebral  symptoms  which 
appear  during  the  progress  of  the  case  are  variable,  the  most 
usual  being  convulsions,  attacks  of  laryngismus  stridulus, 
paralyses,  of  varying  distribution,  with  contractures,  strabismus, 
rolling  of  the  eyeballs,  and  amblyopia  progressing  to  amaurosis. 
Hearing,  as  a  rule,  remains  unaffected  until  near  the  fatal 
termination. 

§  850.  Course,  Duration,  and  Terininations. — Almost  every 
case  of  chronic  hydrocephalus  proves  fatal.  A  large  number 
die  from  some  intercurrent  disease,  others  from  laryngismus 
stridulus,  or  general  convulsions.  The  disease  usually  lasts 
one  to  two  years,  occasionally  longer ;  exceptionally,  patients 
affected  with  chronic  hydrocephalus  have  been  known  to  live 
to  thirty  (Bright)  or  even  to  seventy-eight  years  of  age 
(Trousseau). 


DISEASES   OF   THE   MEMBRANES   OF   THE  BRAIN.  773 

§  851.  Morbid  Anatomy. — In  chronic  hydrocephalus  the 
general  ventricular  cavity  of  the  encephalon  is  distended  with 
serous  fluid,  which  varies  in  quantity  from  a  few  ounces  to 
many  pounds.  The  ventricular  cavities  are  consequently  greatly 
enlarged,  the  openings  by  which  they  communicate  with  one 
another  are  dilated,  and  the  septum  lucidum,  commissures, 
fornix,  and  corpus  callosum  are  stretched  or  torn,  while  the 
surrounding  cerebral  substance  may  be  softened,  of  normal  con- 
sistence, or  unusually  dense.  The  cerebral  hemispheres  are 
compressed  and  flattened;  the  convolutions  are  pressed  out 
and  the  sulci  disappear,  the  white  and  grey  substances  being 
scarcely  distinguishable.  The  basal  ganglia  are  pressed  down- 
wards, the  cerebral  peduncles  are  separated,  the  optic  commis- 
sure is  compressed,  the  pons  varolii  and  corpora  quadrigemina 
are  distorted,  the  superior  surface  of  the  cerebellum  is  flattened, 
and  the  nerves  at  the  base  of  the  brain  are  compressed. 

The  membranes  of  the  brain  are  rendered  thin  and  softened, 
but  the  ependyma  of  the  ventricles  is  sometimes  found 
thickened,  rough,  and  in  a  granular  condition.  The  bones  of 
the  skull  are  generally  thin  and  transparent,  but  in  some  cases 
they  are  of  normal  thickness,  while  in  a  few  cases  they  are 
thicker  than  normal,  being  then  unusually  dense  and  resisting. 

§  852.  Morbid  Physiology. — Many  pathologists  believe  that 
the  effusion  of  chronic  hydrocephalus  is  a  passive  dropsy,  but 
Rokitansky  and  others  are  of  the  opinion  that  it  results  from 
a  chronic  inflammation  of  the  ependyma  of  the  ventricles  and 
the  choroid  plexuses.  The  symptoms  are  partly  due  to  dis- 
placement of  the  cranial  bones,  and  partly  to  the  compression 
of  the  substance  of  the  encephalon. 

§  853.  Diagnosis. — Congenital  hydrocephalus  may  be  mis- 
taken for  encephalocele,  but  in  the  latter  affection  the  swelling  is 
local ;  it  is  doughy  and  elastic  instead  of  being  fluctuating,  and 
is  not  transparent.  Fungus  of  the  dura  mater,  that  has  per- 
forated at  birth,  also  forms  a  local  tumour,  which  appears  over 
one  of  the  bones  perforated  by  it,  and  not  over  the  sutures  or 
fontanelles,  while  the  mass  feels  doughy,  and  when  pressed 
upon  symptoms  of  irritation  are  produced. 


774  DISEASES   OF  THE   MEMBRANES   OF  THE  BRAIN. 

The  enlargement  of  the  head  observed  in  rickets  may  be 
mistaken  for  chronic  hydrocephalus.  In  the  former  the  en- 
largement of  the  head  follows  other  evidences  of  the  general 
affection,  while  in  hydrocephalus  rickets  is  either  absent  or 
develops  subsequently  to  the  enlargement  of  the  head,  and  this 
is  never  so  uniform  in  rickets  as  in  hydrocephalus. 

The  enlargement  of  the  head  which  occurs  in  hypertrophy 
of  the  brain  may  be  mistaken  for  hydrocephalus,  but  in  the 
former  affection  the  head  enlarges  at  first  without  producing 
symptoms,  and  when  these  appear  the  disease  pursues  an  acute 
course  and  terminates  rapidly  in  death. 

§  854.  Prognosis. — The  prognosis  is  always  grave,  although 
isolated  cases  have  been  known  to  live  to  old  age.  The 
prognosis  with  regard  to  the  restoration  of  the  mental  faculties 
is  even  worse  than  that  as  to  life. 

§  855,  Treatment. — Great  attention  should  be  paid  to  the 
general  health,  but  it  is  needless  to  expect  to  obtain  absorption 
of  the  fluid  by  means  of  internal  remedies  or  the  application 
of  counter-irritants.  Methodical  compression  of  the  head  by 
means  of  adhesive  plaster  has  been  recommended,  but  has  not 
been  productive  of  any  good.  The  treatment  by  puncture  or 
aspiration,  advised  by  Couquet  and  others,  affords  a  chance  of 
partial  success.  The  puncture  should  be  made  by  a  fine  trochar, 
or  by  the  needle  of  an  aspirator,  which  should  be  introduced 
perpendicularly.  "  The  best  spot  for  puncturing  the  skull,"  says 
Ramskill,  "  is  about  an  inch  or  an  inch  and  a  half  from  the 
anterior  fontanelle,  near  the  edge  of  the  coronal  suture,  taking 
care  to  avoid  the  longitudinal  sinus  and  some  of  the  large  veins 
which  empty  themselves  into  it."  Only  a  few  ounces  of  fluid 
should  be  slowly  withdrawn  at  a  time,  the  skull  being  at  the 
same  time  supported  by  bandages. 

3.    Simple  Meningitis  op  the  Base  or  the  Brain. 
(Basilar  Meningitis.) 

§  856.  Etiology. — Inflammatory  processes  at  the  base  of  the 
brain  are  frequently  caused  by  fissures,  tumours,  abscesses,  and 
other  lesions  near  the  base  of  the  brain,  but  cases  of  this  kind 


DISEASES   OF   THE   MEMBRANES   OF   THE  BRAIN.  775 

have  already  been  sufficiently  considered.  That  form  of  basal 
meningitis  only  is  to  be  considered  at  present  which  arises 
spontaneously  or  from  unknown  causes.  Nearly  all  those 
affected  are  from  16  to  80  years  of  age,  and  in  most  of  them 
hereditary  predisposition  to  tuberculosis  is  wanting. 

§  857.  Symptoms.  —  When  primary  basilar  meningitis  is 
diffused  and  general,  the  affection  begins  by  languor,  mental 
depression,  chilliness  or  even  rigor,  thirst,  and  the  usual  symp- 
toms of  fever.  The  patient  complains  of  intense  cephalalgia 
and  giddiness,  and  these  are  followed  by  severe  attacks  of 
vomiting. 

Motor  disturbances  may  be  completely  absent  throughout  the 
whole  course  of  the  affection.  When  present,  they  consist  of 
spasmodic  rigidity  of  the  muscles  of  the  back  of  the  neck,  with 
retraction  of  the  head,  and  rarely  of  rigidity  or  clonic  twitch- 
ings  of  certain  groups  of  the  muscles  of  the  extremities.  The 
patient  grinds  his  teeth  during  sleep;  and  in  the  later  stages 
of  the  affection,  trismus  and  hiccough  have  been  observed. 
Paralysis  of  the  abducens  is  not  uncommon,  but  paralysis  of 
the  oculo-motor  nerve  is  rare.  Paresis  of  the  facial  or  hypo- 
glossal nerves  may  occur  temporarily  during  the  course  of 
the  affection  and  subsequently  disappear,  but  complete  para- 
lysis of  them  has  not  been  observed.  The  power  of  degluti- 
tion may  be  impaired  during  the  course  of  the  affection  and 
be  afterwards  regained,  and  this  may  increase  to  complete 
dysphagia  before  death.  Paresis  of  the  extremities  is  occa- 
sionally observed,  but  never  complete  paralysis. 

The  sensory  disturbances  consist'  of  cutaneous  hyperaesthesia, 
especially  in  the  region  of  distribution  of  the  fifth  nerves, 
ringing  in  the  ears,  scintillations  before  the  eyes,  and  occa- 
sionally hallucinations.  Anaesthesia  and  dyssesthesiae  have  not 
been  observed.  The  psychical  disturbances  are  more  variable 
than  in  any  other  form  of  meningitis.  In  some  cases  the 
mental  faculties  are  unaffected  throughout  the  whole  course  of 
the  disease,  while  in  others  they  are  early  involved.  The 
mental  symptoms  usually  consist  of  a  mild  delirium  ;  but  in 
exceptional  cases  this  may  be  more  active,  the  patient  being 
restless,  quarrelsome,  capricious,  and  irascible.     Active  delirium 


776  DISEASES   OF  THE  MEMBRANES   OF   THE  BRAIN. 

is  usually  temporary  aad  sodh.  gives  place  to  a  milder  form ; 
the  patient  after  a  time  becomes  somnolent,  but  may  be  tem- 
porarily aroused  by  a  loud  question  addressed  to  him;  in  a 
short  time  he  falls  into  a  state  of  complete  insensibility,  during 
which  the  urine  and  faeces  are  passed  involuntarily.  Vomiting 
continues  to  distress  the  patient  throughout  the  course  of  the 
disease,  the  bowels  are  constipated,  but  the  abdomen  is  not 
retracted  as  in  tubercular  meningitis. 

The  temperature  curve  is  very  irregular.  In  the  initial 
period  it  may  rise  as  high  as  104°  F.  in  the  evening  and  approach 
to  the  normal  in  the  morning.  In  the  later  stages  of  the 
disease  the  temperature  remains  low,  being  sometimes  sub- 
normal. The  pulse,  as  a  rule,  follows  the  temperature,  being 
very  frequent  in  the  initial  period,  and  sinking  in  the  course 
of  the  disease  to  below  60  beats  in  the  minute.  Towards  the 
end  of  life  it  again  increases,  and  becomes  very  frequent, 
irregular,  and  intermittent ;  the  patient  is  covered  with  bed- 
sores, much  emaciated,  and  dies  in  a  state  of  marasmus. 

The  chronic  forms  of  basilar  meningitis  may  give  rise  to 
localised  inflammatory  products  at  the  base  of  the  brain,  which 
cause  symptoms  scarcely  to  be  distinguished  from  those  of 
tumours  occupying  the  same  situation.  The  symptoms  are 
variable  in  such  cases,  the  most  characteristic  being  paralyses 
of  the  various  cranial  nerves.  In  addition  to  the  headache  and 
dizziness,  there  are  anosmia,  amaurosis,  or  hemianopsia,  ptosis, 
paralysis  of  the  motor  nerves  of  the  eyeball,  sensory  distur- 
bances in  the  region  of  distribution  of  the  fifth  nerve,  masti- 
catory paralysis,  paresis  of  the  seventh  nerve,  and  occasionally 
paresis  of  one  or  more  of  the  extremities.  If  the  inflammation 
extend  to  the  lower  end  of  the  pons,  bulbar  paralysis,  dysphagia, 
and  dyspnoea  may  be  present. 

§  858.  Course,  Duration,  and  Terminations.  —  Basilar 
meningitis  generally  begins  suddenly  without  premonitory 
symptoms.  The  course  of  the  affection  is  variable,  being  inter- 
rupted by  remissions  and  exacerbations.  The  duration  of  the 
disease  extends  from  a  period  of  seventeen  to  sixty-four  days. 
In  chronic  cases  it  may  be  prolonged  over  a  period  of  months  ; 
the  symptoms  are  in  such  cases  more  or  less  similar  to  those  of 


DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN.  777 

tumour  situated  at  the  base  of  the  skull.  The  affection  generally 
terminates  in  death. 

§  859.  Morbid  Anatomy. — The  changes  found  at  the  base  of 
the  brain  vary  according  to  the  rapidity  of  the  process.  In  the 
most  acute  cases  purulent  infiltration  of  the  pia  mater  of  the 
base  from  the  chiasma  to  the  posterior  margin  of  the  pons 
has  been  found.  This  infiltration  may  extend  along  the  fissure 
of  Sylvius  for  some  distance,  but  does  not  reach  the  convexity 
of  the  brain  ;  on  the  other  hand,  it  often  extends  along  the 
whole  transverse  diameter  of  the  hemispheres,  frequently  in- 
volving the  choroid  plexuses  and  the  ependyma  of  the  ventricles. 
The  ventricles  are  generally  distended  with  fluid,  while  the 
convolutions  are  flattened  and  the  sulci  pressed  together.  In 
less  acute  cases  the  inflammatory  exudation  induces  various 
degrees  of  thickening  of  the  pia  mater.  The  choroid  plexuses 
are  increased  in  size,  indurated,  and  may  at  times  be  covered 
with  pus. 

§  860.  Diagnosis. — Basilar  meningitis  may  run  a  course  so 
similar  to  typhoid  fever  that  the  two  affections  can  only  be  dis- 
tinguished by  long-continued  observation.  When  the  tempera- 
ture curves  of  the  two  affections  are  similar,  the  points  to  be 
relied  on  in  forming  a  diagnosis  are  the  presence  in  typhoid  form 
of  diarrhoea,  rose-coloured  spots  over  the  abdomen,  and  enlarge- 
ment of  the  spleen. 

§  861.  Prognosis. — Most  cases  end  in  death,  but  some  are 
recorded  in  which  the  symptoms  corresponded  closely  with  those 
of  basilar  meningitis  and  which  ended  in  recovery. 

§  862.  Treatment. — Counter  irritation  in  various  forms  has 
been  employed  with  good  effect,  but  this  remedy  should  be 
reserved  for  the  later  stage  of  the  disease.  Quinine,  mercury, 
and  iodine  have  been  employed,  but  with  doubtful  success. 
The  headache  must  be  allayed  by  narcotics.  If  syphilis  be 
present,  mercurial  inunction  and  iodide  of  potassium  should  be 
employed. 


778  DISEASES   OF  THE  MEMBRANES   OF   THE  BRAIN. 

4.  Menikgitis  of  the  Convexity  of  the  Bkain. 
This  aflfection  may  either  be  primary  or  secondary,  acute 
or  chronic. 

§  863.  Etiology. — Simple  primary  meningitis  of  the  convexity 
is  a  rare  affection.  It  may  occur  at  all  ages,  but  chiefly  attacks 
infants  under  two  years  of  age,  and  occurs  with  decreasing 
frequency  from  this  age  to  puberty,  when  it  becomes  more  fre- 
quent. Acute  meningitis  is  rare  in  advanced  age,  but  the  chronic 
form  is  frequent.  Of  adults,  men  are  more  liable  to  the  disease 
than  women.     The  exciting  causes  are  not  well  known. 

Secondary  meningitis  of  the  convexity  may  be  produced  by 
inflammation  of  the  bones  of  the  skull,  the  usual  causes  of  the 
latter  being  external  injury,  scrofula,  and  syphilis.  Gummata 
may  also  give  rise  to  this  inflammation.  Otorrhoea,  especially 
when  complicated  by  caries  of  the  temporal  bone,  is  one  of  the 
most  frequent  causes  of  purulent  meningitis,  and  the  affection 
may  result  from  puriform  softening  of  a  thrombus  in  one  of  the 
sinuses,  erysipelas  of  the  head  leading  to  osteo-phlebitis  of  the 
bones  of  the  skull,  carbuncles  of  the  face  and  neck,  suppuration 
of  the  eyeball,  and  old  intracranial  diseases  like  tumours, 
abscesses,  or  necrotic  softening. 

§  864.  Symptoms. — The  course  of  acute  meningitis  may  be 
divided  into  three  stages  :  (1)  The  period  of  excitement ;  (2)  The 
period  of  transition ;  and  (3)  The  stage  of  collapse. 

(1)  The  Period  of  Excitement. — Obscure  premonitory  symp- 
toms are  sometimes  observed,  consisting  usually  of  a  feeling  of 
heaviness  in  the  head  along  with  paroxysms  of  violent  cephal- 
algia, sleeplessness,  irritability  of  temper,  and  general  malaise. 
As  a  rule,  however,  the  disease  begins  suddenly  by  a  well-marked 
rigor,  intense  headache,  vomiting,  fever,  and  delirium,  while  in 
children  it  is  ushered  in  by  an  attack  of  general  convulsions. 

The  headache  may  be  diffused,  or  referred  to  the  forehead, 
temples,  vertex,  or  occiput ;  it  is  intensified  by  light  and  sound, 
and  by  all  movements  of  the  head.  The  patient  consequently 
shuns  the  light,  and  holds  his  head  between  his  hands,  in 
order  to  prevent  it  from  moving.  The  headache  is  continuous, 
but    is  marked  by   exacerbations  of  intense  severity,  during 


DISEASES  OF  THE  MEMBRANES   OF   THE  BRAIN.  779 

which  the  patient,  especially  if  a  child,  may  utter  a  loud  and 
piercing  cry. 

Yomiting  is  a  very  constant  symptom  of  meningitis,  and  is, 
like  the  vomiting  symptomatic  of  other  cerebral  diseases,  unat- 
tended by  nausea,  and  epigastric  pain  or  tenderness.  It  recurs 
frequently  during  the  first  forty-eight  hours,  and  may  then  cease 
or  occur  at  intervals  throughout  the  course  of  the  affection. 

The  motor  disturbances  in  this  stage  are  not  well  marked, 
if  the  general  convulsions  which  usher  in  the  disease  in  chil- 
dren, and  which  may  also  frequently  recur  in  the  course  of  the 
affection,  be  excepted.  The  patient  staggers  like  a  person 
drunk  when  he  attempts  to  walk,  and  when  confined  to  bed  he 
is  restless  and  keeps  changing  his  position.  Strabismus,  slight 
twitching  of  the  muscles  of  the  face  and  limbs,  and  tonic  spasms 
of  those  of  the  neck  and  back  may  also  be  observed.  The 
pupils  are  usually  contracted  or  unequal  during  this  stage,  but 
react  readily  to  light. 

The  sensory  disturbances  consist  of  buzzing  in  the  ears, 
flashes  before  the  eyes,  and  intolerance  of  light  and  sound. 
Cutaneous  hypersesthesia  is  not  unfrequently  present,  so  that 
the  slightest  touch  on  the  skin  may  cause  pain,  and  the  reflex 
excitability  is  increased. 

The  psychical  disturbances  are  well  marked  from  the  first. 
The  patient  is  extremely  irritable,  and  fierce  delirium  is  apt  to 
occur,  the  patient  shouting  and  violently  struggling  with  his 
attendants.  At  other  times  he  is  morose,  and  buries  his  head 
under  the  bed-clothes,  obstinately  refusing  to  answer  questions. 
The  temperature  of  the  body  is  elevated,  the  pulse  beats 
from  120  to  140  or  more,  and  the  respirations  are  increased  to 
30  or  40  in  the  minute. 

(2)  The  Period  of  Transition. —  During  this  stage  the 
furious  delirium  of  the  first  stage  becomes  quieter,  the  patient 
lies  on  his  back,  with  his  fingers  picking  at  the  bed-clothes  or 
catching  at  imaginary  flies  in  the  air. 

More  pronounced  motor  disturbances  now  make  their  appear- 
ance, consisting  of  partial  or  general  convulsions,  followed  by 
paralysis.  The  muscles  most  commonly  affected  by  partial 
convulsions  are  those  of  the  eyeballs,  producing  strabismus;  the 
same  muscles  in  conjunction  with  those  of  the  neck  causing 


780  DISEASES   OF  THE  MEMBRANES   OF  THE  BRAIN. 

conjugate  deviation  of  the  eyes  and  rotation  of  the  head;  the 
muscles  of  the  face ;  those  of  the  jaws  causing  grinding  of  the 
teeth  and  trismus ;  those  of  the  tongue  causing  various  distor- 
tions of  the  organ  ;  the  small  muscles  of  the  hand  causing 
jerking  movement  of  the  fingers,  subsultus,  and  tremor  of  the 
hands  ;  and,  lastly,  the  larger  muscles  of  the  extremities  giving 
rise  to  various  convulsive  movements  of  the  limbs.  It  is 
probable  that  the  loud  cry  which  the  patient  continues  to 
utter  occasionally  in  this  stage  is  not  a  voluntary  action,  but 
caused  by  spasmodic  contraction  of  the  associated  muscles  of 
vocalisation.  The  muscles  of  the  neck  and  back  are  liable  to 
be  affected  by  tonic  spasm,  causing  retraction  of  the  head  with 
attacks  of  opisthotonos. 

These  convulsive  symptoms  are  followed  by  paralysis,  which 
is  very  variable  in  its  distribution,  some  groups  of  muscles 
being  paralysed  while  others  continue  convulsed. 

The  sensory  disturbances  consist  of  dimness  of  vision  and  of 
hearing,  ending  in  blindness  and  deafness,  while  the  general 
cutaneous  hypergesthesia  of  the  first  stage  is  replaced  by 
anaesthesia.  The  bowels  are  constipated  throughout,  and  the 
abdominal  walls  are  often  retracted  as  in  tubercular  meningitis. 
The  respirations  are  irregular,  the  pulse  frequent  and  thready, 
and  there  is  retention  of  urine. 

(3)  The  Stage  of  Collapse. — The  third  stage  of  the  affection 
now  becomes  established  ;  the  convulsive  phenomena  give 
place  everywhere  to  paralysis,  and  the  patient  passes  into  a 
profound  and  fatal  coma. 

Symptoms  of  Secondary  Meningitis. — The  symptoms  of 
secondary  meningitis  differ  considerably  according  to  the  cause 
of  the  inflammation ;  but,  inasmuch  as  inflammation  from 
caries  of  the  petrous  bone  is  the  most  usual  form  of  the  affec- 
tion, it  will  be  useful  to  describe  it  first. 

The  affection  may  be  ushered  in  by  chilliness  or  a  distinct 
rigor  and  feverish  symptoms;  but  intense  headache,  either  con- 
tinuous or  marked  by  remissions  and  exacerbations,  is  the  first 
symptom  to  direct  attention  to  the  brain.  The  headache  may 
be  fixed  to  a  point  in  the  vicinity  of  the  diseased  ear,  or  shoot 
from  one  ear  to  another,  while  at  other  times  it  is  diffused  over 
the  whole  head.     If  the  local  affection  be  attended  by  pain. 


DISEASES  OF  THE  MEMBRANES  OF  THE  BRAIN.  781 

the  commencement  of  the  meningitis  is  marked  by  a  great 
increase  of  its  intensity,  and  the  onset  of  the  latter  may 
sometimes  be  completely  masked  by  an  increase  of  the  local 
inflammation  in  the  ear.  Attacks  of  dizziness  now  supervene, 
accompanied  by  nausea  and  vomiting;  the  patient  complains 
of  noises  in  the  head,  general  painful  sensations  diffused  over 
the  body,  and  obscuration  of  the  spinal  senses. 

After  a  paroxysm  of  intense  cephalalgia,  the  patient  begins 
to  wander,  or  becomes  actively  delirious ;  these  symptoms 
may,  however,  disappear  temporarily.  The  initial  symptoms 
are  accompanied  or  preceded  by  the  signs  of  local  disease,  con- 
sisting of  transitory  phenomena  of  irritation  followed  by  those 
of  depression.  The  signs  of  motor  irritation  are  rigidity  of 
the  muscles  of  the  nape  of  the  neck,  convulsive  twitching  of 
the  facial  muscles  on  the  affected  side,  trismus,  grinding  of  the 
teeth,  and  occasionally  spasms  of  the  extremities. 

The  depressive  symptoms  consist  of  paralysis  of  the  facial, 
hypoglossal,  and  glosso-pharyngeal  nerves  on  the  same  side  as 
the  lesion;  while,  if  the  inflammation  extend  forwards  along 
the  base  of  the  skull,  the  third,  fourth,  sixth,  and  probably  the 
fifth  nerves  may  become  involved  iu  inflammation.  The  state 
of  the  pupils  is  variable  and  liable  to  frequent  changes  during 
the  course  of  the  disease,  being  generally  contracted  or  unequal 
at  first,  and  dilated  and  fixed  when  effusion  has  taken  place. 
Paralysis  of  the  extremities  is  rare,  but  the  patient  has  an 
unsteady,  staggering  gait. 

The  sensory  disturbances  consist  of  marked  hypersesthesia 
of  the  skin,  joints,  bones,  and  muscles,  so  that  every  movement 
is  painful. 

Vomiting  generally  continues  throughout  the  whole  course  of 
the  disease,  the  bowels  are  constipated,  and  the  abdominal 
muscles  are  tender  to  the  touch  and  retracted.  The  temperature 
in  acute  cases  is  usually  high,  but  remits  in  the  morning, 
although  it  remains  constantly  high  in  some  cases. 

The  pulse  as  a  rule  rises  and  falls  in  frequency  along  with 
the  temperature,  except  in  the  cases  where  symptoms  of  com- 
pression of  the  brain  occur  during  the  first  days  of  the  disease. 

The  urine  is  often  albuminous,  and  this  may  or  may  not  be 
associated  with  amyloid  disease  of  the  liver,  spleen,  and  kidneys. 


782  DISEASES   OF  THE   MEMBRANES   OF   THE  BRAIN. 

The  optic  discs  usually  present  the  same  appearances  as  those 
observed  in  tubercular  meningitis.  The  psychical  symptoms 
are  very  variable,  consisting  of  jactitation,  restlessness,  and 
confusion  of  ideas,  especially  towards  the  evening  when  the 
temperature  rises.  After  a  time  the  patient  falls  into  a  somno- 
lent condition,  from  which  he  can  at  first  be  readily  roused  by 
a  loud  question,  but  this  state  soon  gives  place  to  profound  and 
fatal  coma. 

§  865.  Course,  Duration,  and  Terminations. — The  duration 
of  simple  purulent  meningitis  is  variable,  but  as  a  rule  the  pro- 
gress of  the  case  is  rapid.  The  disease  may  terminate  in  adults 
within  a  week,  and  in  infants  in  a  still  shorter  period,  but 
sometimes  it  may  assume  a  more  or  less  chronic  form,  death 
resulting  after  weeks  or  months. 

The  duration  of  purulent  meningitis,  secondary  to  disease  of 
the  temporal  bone,  varies  from  a  period  of  twenty-four  hours 
to  two  or  three  weeks,  and  the  affection  is  usually  fatal. 

§  866.  Morbid  Anatomy.-— The  pia  mater  is  infiltrated  with 
a  fibro-purulent  exudation,  the  convexity  being  usually  in- 
volved to  a  greater  extent  than  the  base,  although  the  latter 
is  generally  more  or  less  implicated,  and  the  exudation  may 
ev^n  extend  over  the  pia  mater  of  the  cerebellum  and  medulla 
oblongata.  The  effusion  into  the  ventricles  varies  in  quantity, 
and  is  generalij  sero-purulent  in  character.  Pus  may  some- 
times be  found  in  the  tissue  of  the  choroid  plexuses.  The  pia 
mater  is  usually  adherent  to  the  cortex,  and  on  being  stripped 
off,  portions  of  the  latter  are  torn  off  with  it.  Small  capillary 
extravasations  are  found  in  the  cortex,  or  the  cortex  may  be 
rendered  anaemic  by  the  intra-ventricular  pressure. 

On  microscopic  examination,  the  protoplasm  of  the  ganglion 
cells  is  found  to  be  granular  and  the  cells  themselves  deformed, 
while  the  vessels  are  surrounded  by  emigrant  white  and  red 
blood  corpuscles.  Secondary  meningitis  presents  the  same 
general  morbid  appearances  as  the  primary  variety,  although 
its  distribution  is  not  always  the  same. 

In  the  meningitis  which  results  from  caries  of  the  petrous 
bone,  the  changes  may  at  times  be  limited  to  the  pons  and 


DISEASES   OF   THE  MEMBRANES   OF   THE  BRAIN.  783 

neighbouring  parts,  while  at  other  times  the  base  and  the  con- 
vexity of  one  or  of  both  hemispheres  are  implicated.  The 
inflammation  generally  begins  on  the  inferior  surface  of  the 
temporal  lobe,  and  extends  to  the  superior  and  inferior  surfaces 
of  the  cerebellum,  the  anterior  surface  of  the  pons,  and  even 
into  the  vertebral  canal. 

If  the  meningitis  be  caused  by  thrombosis  of  the  sinuses,  the 
morbid  appearances  characteristic  of  the  latter  affection  are 
found  in  addition  to  those  indicative  of  meningitis. 

§  867.  Diagnosis. — Simple  purulent  meningitis  is  a  rare 
disease  and  occurs  most  frequently  in  youth  and  manhood, 
•  while  the  tubercular  variety  is  much  more  common  and  occurs 
most  frequently  between  the  second  and  seventh  years  of  age. 
The  prodromata  in  simple  meningitis  are  not  well  marked; 
the  disease  is  suddenly  developed  in  apparently  healthy  per- 
sons, and  its  onset  is  marked  by  rigors,  while  in  the  tubercular 
form  the  patient  has  been  losing  flesh  for  weeks  before  the 
commencement  of  the  attack,  and  the  disease  is  developed 
more  gradually. 

The  delirium  is,  as  a  rule,  more  violent  in  primary  than  in 
tubercular  meningitis,  while  the  paralytic  symptoms  are  on  the 
other  hand  more  pronounced  in  the  latter.  Partial  convulsions 
are  more  characteristic  of  tubercular,  and  general  convulsions 
of  simple  purulent  meningitis,  while  rigidity  of  the  muscles 
of  the  neck,  and  tetanic  spasms  of  the  muscles  of  the  trunk 
are  equally  common  in  both  affections,  but  retraction  of  the 
abdominal  muscles  is  not  so  marked  in  simple  as  in  tubercular 
meningitis.  Cutaneous  hypersesthesia  is  more  commonly  ob- 
served in  the  simple  than  in  the  tubercular  form. 

Meningitis  arising  from  caries  of  the  petrous  bone  can  hardly 
be  distinguished  from  tubercular  meningitis  associated  with 
disease  of  the  same  bone.  Meningitis  from  thrombosis  of  the 
sinuses  must  be  distinguished  by  the  signs  of  the  latter  already 
described ;  and  the  diagnosis  between  purulent  meningitis  and 
abscess  of  the  brain  has  already  been  considered. 

§  868.  Prognosis. — Several  recorded  cases  appear  to  show 
that  recovery  may  take  place  in  the  early  stage  of  simple  puru- 


784  j        DISEASES   OF   THE  MEMBRANES   OF   THE  BRAIN. 

lent  meningitis,  but  in  such  cases  the  diagnosis  must  always 
remain  doubtful;  when  the  disease  is  once  fully  developed, 
recovery  is  probably  no  longer  possible.  The  prognosis  of  acute 
secondary  meningitis  is  always  unfavourable ;  in  a  few  fortunate 
cases,  where  the  affection  is  secondary  to  an  abscess,  the  contents 
of  the  latter  may  escape  and  recovery  ensue. 

§  869,  Treatment. — In  the  first  stage  of  the  disease  the  usual 
antiphlogistic  treatment  must  be  adopted,  consisting  of  leeching, 
purgation,  and  cold  applied  to  the  shaven  scalp.  When  the 
cephalalgia  is  intense,  narcotics  may  be  cautiously  administered, 
the  best  being  a  small  dose  of  morphia,  subcutaneously  injected. 
Chloral  hydrate,  either  alone  or  in  combination  with  bromide 
of  potassium,  is  useful  when  there  is  much  restlessness  and 
mental  excitement.  Mercury  and  iodide  of  potassium  have 
been  give  a  with  the  view  of  promoting  absorption,  but  the 
affection  appears  to  be  much  too  acute  for  the  action  of  these 
drugs. 

5.    Metastatic  Meningitis. 

Metastatic  meningitis  comprises  certain  varieties  of  the 
affection,  which  occur  as  terminal  phenomena  in  the  course  of 
acute  diseases. 

§  870.  Etiology. — The  diseases  with  which  meningitis  is 
most  frequently  associated  are  pneumonia,  ulcerative  endo- 
carditis, acute  rheumatism,  purulent  pleurisy,  pericarditis, 
diphtheria,  and  the  acute  exanthemata.  Although  chronic 
Bright's  disease  is  liable  to  be  complicated  by  inflammation 
of  the  serous  membranes,  mecingitis  is  rare. 

§  871.  Symptoms. — The  extent  and  intensity  of  the  inflam- 
mation vary  greatly  in  different  cases;  in  some  there  is  little 
or  no  effusion  into  the  ventricles,  and  the  symptoms  of  com- 
pression are  absent;  the  inflammation  is  sometimes  limited  to 
the  convexity,  and  at  other  times  extends  to  the  base  and 
upper  part  of  the  spinal  cord ;  and  in  the  meningitis  of  acute 
febrile  diseases  the  symptoms  are  obscured  by  the  cerebral 
disturbance  usually  observed  in  all  grave  acute  affections. 


DISEASES   OF   THE   MEMBRANES   OF   THE   BRAIN.  785 

§  872.   Varieties  of  Metastatic  Meningitis. 

Meningitis  with  Pneumonia.  —  Meningitis  may  appear  in 
the  course  of  pneumonia  from  the  third  to  the  eighth  day  or 
even  later.  The  most  usual  symptoms  are  chilliness,  intense 
headache,  rapidly  developed  and  mild,  or  occasionally  furious, 
delirium,  a  fresh  accession  of  fever,  and  hyperpyrexia  before 
death.  The  delirium  gives  place  at  an  early  period  to  somno- 
lency, ending  in  coma.  A  slight  degree  of  rigidity  and  pain 
in  the  neck  is  always  a  valuable  sign  of  meningitis,  and 
vomiting  is  a  frequent  occurrence.  The  pupils  are  generally 
contracted  at  first,  and  may  subsequently  become  unequal.  If 
the  base  of  the  brain  be  affected,  paralysis  of  the  ocular  motor 
and  other  nerves  at  the  base  of  the  skull  render  the  nature 
of  the  complication  more  apparent. 

Meningitis  ivith  Ulcerative  Endocarditis. — The  cerebral 
symptoms  in  ulcerative  endocarditis  are  caused  by  multiple 
hsemorrhagic  infarctions  of  the  cortex  of  the  brain  or  of  the  pia 
mater,  and  the  symptoms  produced  are'  more  or  less  like  those 
of  pysemic  encephalitis. 

A  rheumatic  meningitis  has  been  described,  but  post-mortem 

evidence  of  its  existence  is  wanting. 

§  873.  Morhid  Anatomy  — The  amount  of  blood  in  the 
vessels  of  the  pia  mater  and  brain  is  variable.  The  exudation 
on  the  pia  mater  is  usually  purulent,  and  varies  in  quantity 
from  a  few  specks,  scarcely  appreciable  to  the  naked  eye,  to  a 
layer  extensively  distributed  over  the  surface  of  the  brain.  The 
layer  of  pus  may  be  limited  to  the  convexity,  or  extend  to  the 
base  of  the  brain.  The  effusion  into  the  ventricles  also  varies 
greatly  both  in  quantity  and  quality.  The  ependyma  and 
plexuses  are  not  much  changed.  It  is  probable  that  the  sub- 
stance of  the  brain,  more  especially  that  of  the  cortex,  is 
involved  in  the  inflammatory  process. 

§  874.  Diagnosis,  Prognosis,  and  Treatment — The  diagnosis 
must  be  made  from  the  presence  of  symptoms  which  indicate 
a  meningitis  supervening,  in  the  course  of  such  diseases,  as 
pneumonia,  or  ulcerative  endocarditis.    The  prognosis  is  always 

Y  Y 


786  DISEASES   OF  THE   MEMBRANES   OF  THE  BRAIN. 

unfavourable,  and  the  treatment  must  be  conducted   on  the 
same  general  principles  as  that  of  other  forms  of  meningitis, 

6.  Traumatic  Meningitis. 
In  traumatic  as  in  other  forms  of  meningitis  the  cortex  of  the 
brain  is  involved  in  the  inflammatory  action,  so  that  the  con- 
dition   would   be   more   accurately   described   as   a   meningo- 
encephalitis. 

§  875.  Etiology. — This  form  of  meningitis  may  appear  during 
the  period  of  reaction  from  concussion,  or  follow  a  contusion  of 
the  brain.  Injury  of  the  scalp,  with  subsequent  inflammation 
of  the  bones  of  the  skull  and  dura  mater,  may  also  give  rise  to 
inflammation  of  the  pia  mater  and  brain.  At  other  times  the 
inflammatory  process  is  set  up  by  a  perforating  injury  of  the 
skull  either  with  or  without  extravasation  of  blood  between  the 
dura  mater  and  the  bone,  the  effects  in  such  cases  being  inten- 
sified by  the  admission  of  air  containing  germs  into  the  open 
wound.  In  other  cases  the  meningitis  is  a  secondary  result  of 
osteitis,  thrombosis  of  the  sinuses  probably  playing  an  important 
part  in  its  production  in  such  cases.  The  meningitis  at  other 
times  may  result  after  necrosis  of  the  bone  has  taken  place. 
Hutchinson  thinks  that  in  fractures  of  the  petrous  portion  of 
the  temporal  bone  the  inflammation  extends  along  the  sheath 
of  the  seventh  nerve,  and  in  this  way  gains  access  to  the  sub- 
arachnoidal spaces. 

§  876.  Symptoms. — This  affection  may  be  divided  into  two 
varieties :  {a)  acute,  and  (6)  chronic  or  subacute  traumatic 
meningo-encephalitis  (Erichsen). 

{a)  Acute  Traumatic  Meningo-Encephalitis. —  The  symp- 
toms of  the  onset  of  the  acute  form  of  the  affection  are  modi- 
fied by  the  fact  that  the  inflammatory  process  usually  attacks 
a  patient  already  suffering  from  the  symptoms  of  concussion, 
compression,  or  contusion  of  the  brain.  It  is  impossible  to 
distinguish  between  the  symptoms  of  the  reaction  period  of 
concussion  and  those  of  the  early  or  congestive  stage  of 
true  inflammation,  so  that  we  are  unable  to  determine  when 
the  symptoms  of  the  former  terminate  and  those  of  the  latter 


DISEASES  OF  THE  MEMBRANES  OF  THE  BRAIN.  787 

begin.  At  the  onset  of  the  inflammatory  attack  the  patient 
complains  of  severe  and  continuous  cephalalgia ;  the  carotids 
beat  forcibly  ;  the  face  is  suffused  and  the  scalp  hot ;  the  pupils 
are  contracted  ;  there  are  intolerance  of  light  and  sound,  spectral 
illusions,  noises  in  the  ears,  and  general  hyperesthesia  to 
external  impressions.  The  patient  likewise  suffers  from  the 
usual  symptoms  of  pyrexia;  the  pulse  is  full  and  bounding, 
and  there  is  restlessness  and  wakefulness  with  delirium  of  a 
violent  character.  These  symptoms  may,  under  proper  treat- 
ment, gradually  subside  until  health  is  re-established;  but  more 
commonly  the  symptoms  of  the  stage  of  irritation  develop  into 
those  of  the  stage  of  compression. 

During  the  stage  of  transition  between  the  early  stage  of 
excitement  and  the  stage  of  compression  of  the  brain  the 
symptoms  of  a  localised  disease  may  make  their  appearance. 
Clonic  or  tonic  spasms,  followed  by  paralysis,  may  occur  in 
particular  groups  of  muscles.  Rigidity  of  the  muscles  of  the 
nape  of  the  neck  with  retraction  of  the  head  is  usually  present 
at  this  period,  and  may  also  extend  to  the  muscles  of  the  back 
and  give  rise  to  tetanic  seizures.  Hemiplegia  of  the  side 
opposite  to  the  injury  is,  according  to  Hutchinson,  a  constant 
symptom  of  direct  traumatic  meningo-encephalitis,  or,  as  he 
terms  it,  arachnitis.  The  abdominal  muscles  are  usually 
retracted  and  the  bowels  constipated.  When  the  meningitis 
is  situated  at  the  base  of  the  brain,  the  cranial  nerves  in  their 
passage  along  the  base  of  the  skull  may  become  implicated.  The 
most  usual  symptoms  produced  are  ptosis,  strabismus,  paralysis 
of  the  facial  muscles  or  of  half  of  the  tongue,  and  difficulty  of 
deglutition. 

The  symptoms  of  compression  of  the  brain  now  become 
rapidly  developed,  the  delirium  is  replaced  by  stupor,  from 
which  the  patient  is  roused  with  difficulty;  the  pupils  are 
dilated  and  insensible  to  light;  the  breathing  is  slow  and 
stertorous;  the  pulse,  retarded  at  first,  becomes  feeble  and 
frequent  towards  the  end ;  the  skin  is  hot  and  bathed  in  per- 
spiration ;  convulsive  twitchings  or  jerkings  of  the  limbs  are 
observed,  but  these  soon  give  place  to  general  muscular  relaxa- 
tion, and  the  patient  dies  in  profound  coma. 

(6)  Subacute  Traumatic  Meningo-Encephalitis. — This  form 


788  DISEASES  OF   THE  MEMBRANES  OF   THE  BRAIN, 

of  meningo-encephalitis  may  come  on  a  few  days  after  the 
injury  or  not  until  months  have  elapsed  (Erichsen).  The 
patient  has  often  apparently  recovered  from  the  original  injury, 
but  as  a  rule  some  of  the  consequences  of  concussion  remain. 
The  patient  in  the  interval  has  complained  of  headache,  im- 
pairment of  sight  and  hearing,  confusion  of  ideas,  or  mental 
irritability.  The  symptoms  of  the  inflammatory  attack  may  be 
ushered  in  by  an  aggravation  of  the  symptoms,  which  have 
persisted  during  the  interval,  or  by  an  epileptic  attack.  The 
pupils  are  contracted,  dilated,  or  unequal;  there  are  intolerance 
of  light  and  sound,  convulsive  twitchings  of  the  limbs  and  face, 
strabismus,  delirium,  and  the  ordinary  phenomena  of  symp- 
tomatic fever.  After  a  time  the  symptoms  of  compression 
supervene,  and  the  patient  dies  comatose. 

§  877.  Course,  Duration,  and  Terminations. — -The  symp^ 
toms  of  acute  traumatic  meningo-encephalitis  sometimes  begin 
a  day  or  two  after  the  injury,  at  other  times  not  until  several 
days  have  elapsed.  In  the  subacute  form  of  the  affection 
weeks  or  months  may  intervene  between  the  injury  and  the 
meningitis. 

The  duration  of  the  disease  varies  within  wide  limits,  the 
average  being  eight  to  fourteen  days. 

§  878.  Morhid  Anatomy  and  Physiology. — The  surfaces  of 
the  visceral  and  parietal  layers  of  the  arachnoid  are  covered 
with  adherent  lymph  of  a  greenish-yellow  and  purulent  appear- 
ance. A  little  fluid  pus  may  sometimes  be  found  between  the 
two  layers  (Hutchinson).  .The  visceral  layer  of  the  arachnoid 
is  congested,  or  thickened  and  semi-opaque.  The  pia  mater  is 
usually  much  congested,  but  it  does  not  appear  to  be  infiltrated 
with  pus  or  covered  by  a  layer  of  lymph  like  the  arachnoid.  The 
substance  of  the  brain  is  congested  and  has  a  rosy  hue,  while 
the  red  points  are  increased  in  number.  The  ventricles  are  filled 
with  a  turbid  serum,  of  a  reddish  colour.  Fracture  of  the  petrous 
bone  gives  rise,  according  to  Hutchinson,  to  inflammation  of  the 
subarachnoid  spaces  at  the  base  of  the  brain.  In  such  cases 
the  inflammation  spreads  along  the  sheath  of  the  seventh  "nerve, 
and  in  this  way  gains  direct  access  to  the  subarachnoid  spaces. 


DISEASES   OF   THE  MEMBRANES   OF   THE   BEAIN.  789 

The  effusion  begins  at  the  base  of  the  brain,  and  may  extend 
upwards  over  the  hemispheres  or  through  the  transverse  fissure 
iato  the  ventricles,  and  may  also  extend  down  the  spinal  cord 
for  a  considerable  distance.  The  effusion  is  always  underneath 
the  visceral  layer  of  the  arachnoid. 

§  879.  Diagnosis  and  Prognosis. — Traumatic  meningo- 
encephalitis may  be  distinguished  from  the  reactive  stage  of 
concussion,  and  from  simple  congestion  of  the  brain  by  the 
elevation  of  the  temperature  and  the  persistence  and  severity 
of  the  symptoms  generally.  The  prognosis  is  always  grave; 
and  in  the  cases  which  are  said  to  recover  it  is  doubtful 
whether  anything  more  than  intense  congestion  of  the  brain 
was  present.  It  is,  however,  important  to  remember  that 
all  the  symptoms  of  the  first  stage  of  traumatic  meningo- 
encephalitis may  have  been  present,  and  yet  that  the  patient 
may  make  a  good  recovery. 

§  880.  Treatment.  —  The  treatment  of  acute  traumatic 
meningo-encephalitis  is  the  same  as  that  of  the  other  acute 
forms  of  meningitis  and  encephalitis.  The  patient  should  be 
confined  in  a  quiet  and  darkened  room  and  removed  from  all 
causes  of  excitement.  The  head  should  be  shaved  and  ice 
applied  to  it.  Erichsen  recommends  bleeding  from  the  arm, 
leeches  or  cupping,  free  purgation,  abstinence,  and  the  ad- 
ministration of  calomel  so  as  to  produce  salivation.  As  the 
case  assumes  a  more  chronic  form  the  treatment  must  be  less 
energetic,  but  the  patient  must  be  kept  for  a  long  time  in  a 
state  of  complete  quietude. 


791 


Part  V.— DISEASES  OF  THE  ENCEPHALO-SFINAL 

SYSTEM. 


CHAPTER  I. 


PARALYSIS    AGITANS,    AND    MULTIPLE    SCLEROSIS. 


(I.)    PARALYSIS   AGITANS 

(Shaking  Palsy — Parkinson's   Disease). 

Paralysis  agitans  is  a  chtonic  nervous  disease  characterised 
by  continuous  tremor  of  the  voluntary  muscles,  and  peculiar 
alterations  in  the  attitudes  of  the  body. 

§  881.  Etiology. — Paralysis  agitans  occurs  in  advanced  life, 
being  rarely  observed  under  forty  years  of  age.  Duchenne  met 
with  the  disease  in  a  youth  of  sixteen,  and  Meschede  in  a  boy 
twelve  years  old  as  the  result  of  having  been  kicked  by  a  horse 
in  the  face.  Men  are  more  frequently  attacked  than  women ; 
hereditary  predisposition  does  not  appear  to  be  an  important 
factor  in  its  production. 

Exposure  to  damp  and  cold  seems  to  be  an  exciting  cause  of 
paralysis  agitans,  the  disease  being  frequently  met  with  amongst 
persons  living  in  damp  and  unhealthy  situations.  It  is  some- 
times caused  by  great  emotional  disturbance,  and  many  cases 
follow  wounds  and  other  injuries. 

§  882.  Symptoms. — The  clinical  history  of  paralysis  agitans 
maybe  divided  into  three  stages:  (1)  The  period  of  invasion; 
(2)  the  stationary  period ;  and  (3)  the  terminal  period. 

(1)  The  Period  of  Invasion. — Paralysis  agitans,  as  a  rule, 
sets  in  somewhat  slowly  and  progressively,  but  occasionally  in 


792  PARALYSIS  AGITANS. 

an  abrupt  manner.     In  the  slow  mode  of  invasion  the  develop- 
ment of  the  disease  may  be  preceded  for  some  time  by  premoni- 
tory symptoms,  such  as  sleeplessness,  mental  irritability,  and  a 
transitory  feeling  of  weakness  in  the  limbs.     The  disease  itself 
is  ushered  in  by  a  trembling  in  one  of  the  extremities,  usually 
beginning  in  the  small  muscles  of  the  hand  or  forearm.     At 
this  stage  the  tremors  are  arrested,  on  the  patient  making  a 
voluntary  effort.     The  tremors  may,  indeed,  cease  when  the 
voluntary   effort  is  unconnected  with  the  members  affected ; 
thus   the   act   of  walking   may   arrest   tremor   of  the   upper 
extremities.     Even  at  this  early  period   the  tremor  presents 
characteristic  features.    If  the  hand  be  affected,  "  the  patient," 
to  quote  Charcot,  "  closes  the  fingers  on  the  thumb,  as  though 
in  the  act  of  spinning  wool;  at  the  same  moment  the  wrist  is 
bent  by  rapid  jerks  on  the  forearm,  and  the  forearm  on  the 
arm."     The  tremor  increases  in  intensity,  and,  instead  of  being 
as   at   first   occasional,   it  gradually   becomes   persistent,  and 
invades  by  degrees  parts  which  have  hitherto  remained  sound. 
The  order  in  which  the  various  muscles  are  invaded  by  the 
tremor  is  somewhat  variable.    The  most  usual  mode  of  invasion 
is  that  which  Charcot  has  called  the  hewiiplegic  type.    In  this 
form  the  tremor  usually  begins  in  the  right  hand,  and  after 
months  or  years  the  lower  extremity  on  the  same  side  becomes 
affected,  and  after  another  variable  period  the  left  hand  and 
foot  are  successively  invaded.     In  other  cases  both  the  lower 
extremities  are  first  affected,  forming   the   para'plegic   type; 
while  in  a  few  cases  the  upper  extremity  of  one  side,  generally 
the  right,  is  first  invaded,  and  then  the  lower  extremity  of  the 
opposite  side,  forming  what  Charcot  calls  the  decussated  mode 
of  invasion.     Charcot  states  that  the  muscles  of  the  neck  and 
head  are  nearly  always  unaffected  by  tremor  at  every  stage  of 
the  disease,  a  fact  which  deserves  particular  notice  inasmuch  as 
it  serves  to  distinguish  paralysis  agitans  from  the  cerebro-spinal 
form  of  disseminated  sclerosis.    The  tremor  may  be  preceded  by 
a  remarkable  feeling  of  fatigue,  or  by  rheumatoid  or  neuralgic 
pains,  and  in  such  cases  it  is  not  uncommon  to  find  that  the 
disease  has  been  occasioned  by  an  injury. 

In  the  abrupt  mode  of  invasion  the  tremor  appears  sud- 
denly either  in  one  extremity  or  in  all  the  limbs  at  once,  and 


PARALYSIS   AGITANS.  793 

the  disease  then  usually  results  from  great  emotional  distur- 
bance. The  tremor  may  soon  diminish  or  disappear,  but  it  recurs, 
and,  after  a  series  of  alternate  exacerbations  and  remissions, 
becomes  permanent.  Whatever  be  the  mode  of  invasion,  the 
duration  of  the  initial  stage  varies  from  one  to  two  or  three 
years. 

(2)  Stationary  Period. — When  the  disease  is  fully  developed 
the  trembling  becomes  almost  incessant,  although  it  varies  in ' 
intensity.     It  is  aggravated  by  emotional  excitement,  cold,  and 
voluntary  effort;    while,   on   the  other  hand,  it  becomes   less 
during  repose,  and  ceases  during  sleep. 

The  different  segments  of  the  hands  and  fingers  undergo 
involuntary  and  rhythmical  oscillations,  which  closely  resemble 
complicated  voluntary  movements.  "  Thus,  in  some  patients," 
says  Charcot,  "  the  thumb  moves  over  the  fingers,  as  when  a 
pencil  or  paper-ball  is  rolled  between  them;  in  others,  the 
movements  are  more  complicated,  and  resemble  what  takes 
place  in  crumbling  a  piece  of  bread."  The  handwriting  now 
assumes  special  characteristics.  At  an  early  stage  of  the  disease 
the  writing  at  the  first  glance  presents  little  change  ;  but,  when 
examined  with  a  magnifying  glass,  inequalities  are  perceived, 
some  parts  being  thicker  and  heavier  than  others.  As  the 
disease  advances  the  up  strokes  become  markedly  tremulous, 
probably  owing  to  the  lumbricales  and  interossei  muscles  being 
most  profoundly  affected  by  the  tremor. 

The  muscles  of  the  head  and  neck,  as  already  stated,  usually 
remain  unaffected.  The  muscles  of  the  eyeballs  are  also  exempt 
from  tremor,  and  consequently  nystagmus,  which  is  so  prominent 
a  symptom  of  disseminated  sclerosis,  has  no  existence  in  para- 
lysis agitans.  The  movements  of  the  eyeballs  are,  however, 
often  executed  with  great  slowness  (Debove).  The  muscles  of 
the  face  instead  of  trembling  are  motionless,  the  features  become 
fixed,  and  the  face  assumes  a  mournful,  stolid,  or  vacant  ex- 
pression. The  utterance  is  slow,  jerky,  and  accomplished  with 
great  apparent  effort,  soon  inducing  weariness,  and  if  the  tremor 
of  the  body  be  intense  it  becomes  tremulous  and  broken,  while 
in  old-standing  cases  the  saliva  may  dribble  from  the  mouth  to 
some  extent. 

After  a  longer  or  shorter  time  the  muscular  power  becomes 


794  PARALYSIS  AGITANS. 

gradually  weakened.  In  many  cases,  however,  motor  weakness 
is  more  apparent  than  real,  the  phenomena  depending  upon  the 
great  slowness  with  which  voluntary  movements  are  executed, 
the  immense  effort  which  all  voluntary  actions,  even  speaking, 
entail,  and  the  readiness  with  which  fatigue  is  induced.  But 
although  the  muscular  power,  when  measured  by  the  dynamo- 
meter, is  often  retained  much  longer  than  might  be  expected, 
yet  after  a  time  motor  power  becomes  gradually  diminished, 
and  paralytic  symptoms  supervene  (Charcot).  The  paralysis, 
however,  almost  always  remains  partial,  and  is  irregularly 
developed  in  different  groups  of  muscles;  and,  as  in  various 
other  forms  of  paralysis,  the  extensors  of  the  limbs  are  affected 
to  a  greater  extent  than  the  flexors.  The  trembling  often 
abates  in  the  muscles  as  paralysis  increases.  The  bladder  and 
rectum  are  only  very  exceptionally  involved  in  the  paralysis. 
The  muscles  react  normally  to  both  the  faradic  and  galvanic 
currents. 

After  a  time  the  muscles  of  the  extremities,  trunk,  and 
neck  become  the  subjects  of  rigidity,  at  first  temporary, 
but  ultimately  becoming  permanent,  the  flexors  being  affected 
to  a  greater  extent  than  the  extensors.  The  rigidity  of  the 
muscles  produces  characteristic  alterations  in  the  attitudes  of 
the  body.  The  rigidity  of  the  anterior  cervical  muscles  causes 
the  head  to  be  strongly  bent  forwards,  and  the  patient  cannot 
raise  it  or  turn  it  to  either  side  without  great  difficulty.  The 
body  is  also  inclined  forwards  when  the  patient  is  standing. 
The  elbows  are  habitually  held  somewhat  removed  from  the 
chest,  the  forearms  are  slightly  flexed  on  the  arms,  and  the  hands 
are  sometimes  flexed,  sometimes  slightly  extended  on  the  fore- 
arms, and  rest  on  the  epigastrium.  The  fingers  are  flexed  at  the 
metacarpo-phalangeal  articulations,  the  index  and  middle  fingers 
are  extended,  but  the  remaining  fingers  are  slightly  flexed,  at  the 
phalangeal  articulations,  all  of  them  are  slightly  inclined  to  the 
ulnar  border  of  the  hand,  and  the  thumb  is  extended  and  op- 
posed to  the  index  finger,  so  that  the  attitude  of  the  hand  and 
fingers  closely  resembles  that  assumed  by  them  in  holding  a 
pen  (Charcot — Fig.  281).  In  some  cases  the  fingers  are  alter- 
nately flexed  and  extended  at  their  several  articulations  so  as 
to  resemble  the  distortions  of  arthritis  deformans  (Fig.  282). 


PAEALYSIS  AGITANS. 


795 


In  paralysis  agilans,  however,  the  joints  are  not  swollen  and 
stiff,  and  passive  movement  of  the  articulations  does  not  give 
rise  to  the  creaking  sounds  observed  in  the  former.  The 
rigidity  of  the  muscles  of  the  lower  extremities  is  sometimes 
so  great  as  to  resemble  paraplegia  with  contracture.  The  spasm 
of  the  adductors  of  the  thighs  and  muscles  of  the  calf  pre- 
dominate over  their  antagonists  so  that  the  knees  are  drawn 

Fig.  281. 


Fig.  281  (After  Charcots    Attitude  of  the  Hand  in  Paralysis  Agitans. 

inwards,  the  leg  is  slightly  flexed  on  the  thigh,  and  the  foot 
assumes  the  well-known  position  of  talipes  equino-varus. 
The  toes  are  extended  at  the  metatarso-phalangeal  and  flexed 
at  the  phalangeal  articulations  (Griffe  des  Orteils). 

Fig.  282. 


Fig.  282  (After  Charcot).     Attitude  of  the  Hand  in  Paralysis  Agitans  simulating 
that  of  Arthritis  Deformans. 

In  the  advanced  stage  of  the  disease  the  patients  move  all 
of  a  piece,  as  if  their  joints  were,  to  use  Charcot's  expression, 
soldered  together;  the  head  and  body  are  kept  inclined  for- 
wards, a  position  which  no  doubt  largely  contributes  to  produce 
that  tendency  to  fall  forwards  manifested  when  walking  (Plate 
IV.,  8  and  4). 

The  gait  of  the  patient  is  now  characteristic.  The  patient 
gets  up  slowly  and  with  difficulty  from  his  seat,  and  hesitates  for 
a  few  moments  before  starting;  when  once  he  has  begun  to  walk, 


796  PARALYSIS  AGITANS. 

he  is  compelled  to  run  forwards,  in  order  to  save  himself  from 
falling.  In  the  language  of  Trousseau,  he  looks  as  if  pursuing 
his  own  centre  of  gravity.  This  gait  has  been  called  paralysis 
festinans  or  proeursoria,  or  simply  propulsion. 

The  forward  running  or  propulsion  is  the  usual  gait  of 
paralysis  agitans,  but  some  patients  manifest  a  strong  tendency 
to  run  or  to  fall  backwards,  although  their  bodies  are  inclined 
forwards,  a  tendency  which  has  been  named  retropulsion. 
Graves  mentions  the  case  of  a  patient  who,  if  arrested  in  his 
forward  movement,  immediately  began  to  run  backwards;  and 
Charcot  could  excite  the  impulse  to  move  backwards  in  a  female 
patient  by  slightly  pulling  her  back  by  the  dress  when  she  was 
standing.  It  has  already  been  mentioned  that  a  few  cases  of 
paralysis  agitans  are  ushered  in  by  rheumatoid  or  neuralgic 
pains,  but  in  the  majority  of  cases  pains  are  absent.  The 
patient  is,  however,  distressed  by  disagreeable  sensations,  as 
cramps  and  sensations  of  tension  and  traction  in  the  muscles, 
along  with  a  general  feeling  of  weariness  and  discomfort.  These 
sensations  render  the  patient  restless,  and  cause  him  to  seek 
frequent  changes  of  posture.  He  complains  of  a  constant  sen- 
sation of  excessive  heat,  although  the  thermometer  shows  that 
the  temperature  of  the  body  is  normal.  In  order  to  relieve 
this  feeling,  the  patient  throws  off  the  bed-clothes  at  night,  and 
only  retains  the  lightest  garments  in  the  day-time  (Charcot). 
This  sensation  of  heat  is  especially  felt  in  the  epigastrium 
and  back,  but  may  affect  the  face  and  limbs.  It  is  liable  to 
remissions  and  exacerbations,  and  seems  to  attain  its  maximum 
after  a  paroxysm  of  trembling ;  it  is  often  accompanied  by 
profuse  perspiration. 

(3)  Terminal  Period. —  The  course  of  the  disease  is  very  • 
protracted,  and  may  extend  over  a  period  of  many  years.  As  the 
tremors  and  muscular  rigidity  increase  in  intensity,  the  patients 
are  compelled  to  remain  the  whole  day  seated  on  a  chair,  or  con- 
fined to  bed.  The  general  nutrition  suffers,  the  muscles  become 
atrophied,  and  the  paresis  of  the  second  stage  of  the  disease 
gives  place  to  pronounced  paralysis.  The  memory  and  in- 
tellect are  weakened,  general  prostration  sets  in,  the  urine 
and  faeces  are  passed  unconsciously,  bed-sores  appear  on  the 
sacrum,   and  the  patient  dies  from   nervous   exhaustion   and 


PARALYSIS   AGITANS.  797 

marasmus.  The  tremors  disappear  entirely  a  few  days  before 
death,  and  paralytic  symptoms  become  predominant.  In  the 
majority  of  cases,  however,  death  results  from  some  inter- 
current disease,  such  as  pneumonia  or  pleurisy. 

§  883.  Morbid  Anatomy. — In  a  very  considerable  number  of 
cases  post-mortem  examination  has  not  revealed  any  lesion  of 
the  nervous  system.  Charcot  examined  three  well-marked 
cases  of  the  disease  in  which  no  lesion  of  the  nervous  system 
could  be  found,  and  individual  cases  have  been  examined  by 
Petraeus,  Olivier,  Th.  Simon,  and  Kiihne  also  with  negative 
results.  Cohn  found  in  one  case  well-marked  cerebral  atrophy, 
but  the  brains  of  old  people  are  frequently  found  in  this  con- 
dition in  the  absence  of  paralysis  agitans.  Meschede,  Bam- 
berger, Lebert,  Marshall  Hall,  and  Skoda  found  sclerotic  patches 
in  various  parts  of  the  cord  and  medulla  oblongata,  pons, 
and  walls  of  the  ventricles,  but  these  were,  doubtless,  cases 
not  of  true  paralysis  agitans,  but  of  disseminated  sclerosis. 
Parkinson  and  Oppolzer  found  induration  of  the  pons,  medulla, 
and  cervical  portion  of  the  cord,  but  these  also  were  probably 
not  cases  of  genuine  paralysis  agitans.  Cayley  and  Murchi- 
son  found  sclerosis  of  the  posterior  part  of  the  spinal  cord, 
thickening  of  the  septa,  enlargement  of  the  central  canal, 
and  aggregation  of  leucocytes  in  spots.  In  three  cases  of 
paralysis  agitans  recently  observed  by  Charcot  and  Joffroy, 
a  microscopical  examination  revealed  changes  in  the  spinal 
cord,  consisting  of  obliteration  of  the  central  canal  by  increase 
of  the  epithelium  of  the  ependyma,  and  pigmentation  of  the 
ganglion  cells,  especially  of  the  columns  of  Clarke.  In  one 
there  was  a  sclerotic  spot  on  the  posterior  surface  of  the  medulla 
oblongata. 

Dowse  and  Kesteven  found  pigmentary  degeneration  of  the 
nerve-cells  near  the  decussation  of  the  anterior  pyramids,  of 
the  cells  of  the  olivary  body,  nucleus  of  the  ninth  nerve, 
laminge  and  corpus  dentatum  of  the  cerebellum,  and  anterior 
cornua  of  the  spinal  cord,  along  with  cortical  sclerosis  of  the 
right  lateral  column  of  the  cord,  and  miliary  changes  in  the 
white  matter  of  the  corpus  striatum  and  hemispheres. 


798  PARALYSIS  AGITANS. 

§  884.  Morbid  Physiology. — As  just  observed,  not  much 
light  has  hitherto  been  thrown  upon  the  pathology  of  paralysis 
agitans  by  morbid  anatomy.  The  results  obtained,  however, 
favour  the  idea  that  the  morbid  changes  are  due  to  a  chronic 
degeneration.  If  the  changes  begin,  as  the  observations  of 
Charcot  and  Joffroy  seem  to  indicate,  around  the  central 
canal  of  the  spinal  cord,  the  small  cells  of  the  accessory  system 
may  be  expected  to  suffer  to  a  greater  extent  than  the  large 
cells  of  the  fundamental  system ;  and  if  the  lesion  consist  in 
part  of  a  thickening  of  the  connective  tissue  septa  of  the  cord, 
as  was  observed  in  Murchison's  case,  the  small  fibres  of  the 
accessory  system,  which  lie  near  the  vessels,  will  be  injured 
by  the  usual  cicatricial  contraction  of  the  new  growth  to  a 
much  greater  extent  than  the  larger  and  more  resisting  fibres 
of  the  fundamental  system.  Even  aggregations  of  leucocytes 
in  the  neighbourhood  of  the  vessels,  such  as  were  found  in 
Murchison's  case,  would  damage  the  accessory  cells  and  fibres 
to  a  greater  extent  than  the  fundamental.  The  results  obtained 
by  Dowse  and  Kesteven,  however,  appear  to  show  that  the 
morbid  changes  in  paralysis  agitans  are  not  limited  to  the 
spinal  cord,  but  are  widely  diffused  in  the  cerebellum  and 
cerebral  hemispheres,  as  indeed  might  be  expected  when  it  is 
considered  that  the  disease  occurs  almost  exclusively  during 
the  degenerative  period  of  life.  It  is  worthy  of  notice  that 
Dowse  and  Kesteven  make  special  mention  of  the  white  matter 
of  the  corpus  striatum,  probably  the  internal  capsule,  as  having 
undergone  morbid  changes. 

Turning  to  the  clinical  history  of  the  disease,  the  most 
prominent  symptoms  are  the  tremors,  the  slowness  in  the 
execution  of  movements,  and  the  peculiar  alteration  in  the 
attitude  of  the  body  with  its  associated  muscular  rigidity.  The 
causes  of  tremor  have  already  been  discussed  (§§  68  and  73).  It 
is  probably  caused  in  this  affection  by  a  diminution  in  the  con- 
ductivity of  the  fibres  of  the  pyramidal  tract,  which  prevents 
impulses  from  the  cortex  reaching  the  muscles  in  suffi- 
ciently close  proximity  to  produce  a  continuous  contraction. 
According  to  this  view,  the  tremors  and  the  slowness  in  the 
execution  of  movements  are  merely  the  first  indications  of 
the    more   pronounced    paralysis    which    supervenes    in    the 


PARALYSIS  AGITANS.  799 

terminal  period.  Another  view,  which  might  be  adopted 
with  regard  to  the  origin  of  the  tremors,  is  that  they  are  caused 
by  a  loss  of  the  balance  normally  existing  between  the  regu- 
lative functions  of  the  cerebrum  and  cerebellum.  The  attitude 
of  paralysis  agitans  is,  as  has  been  pointed  out  by  Hughlings- 
Jackson,  the  opposite  of  that  of  tetanus.  During  a  tetanic 
seizure  the  actions  of  the  extensors  of  the  trunk  and  lower 
extremities  predominate,  and  the  body  is  arched  backwards;  in 
paralysis  agitans  the  action  of  the  flexors  predominates,  so  that 
the  different  segments  of  the  trunk  and  lower  extremities  are 
flexed  upon  one  another.  In  tetanus  the  muscles,  the  actions 
of  which  must  have  gradually  predominated  in  the  course 
of  evolution,  in  the  attainment  of  the  erect  posture,  are  excited 
to  increased  activity;  while  in  paralysis  agitans  the  same 
muscles,  speaking  broadly,  become  relatively  paralysed,  and 
there  is  a  gradual  reduction  of  the  human  to  the  animal 
posture.  A  patient  suffering  from  paralysis  agitans  during  the 
stage  of  propulsion  is,  in  his  attitude,  very  similar  to  a  dog 
attempting  to  walk  on  his  hind  legs.  If,  then,  paralysis  agitans 
be  a  disease  in  which  the  accessory  portion  of  the  nervous  motor 
apparatus  suffers  to  a  greater  extent  than  the  fundamental  part, 
it  may  be  asked  how  it  is  that  the  facial  and  ocular  muscles 
escape  tremor.  I  am  unable  to  give  a  satisfactory  answer  to 
this  question;  but  it  must  be  remembered  that,  although  these 
muscles  do  not  suffer  from  tremor,  yet  they  are  affected  with 
comparative  immobility  and  rigidity  at  a  comparatively  early 
period  of  the  disease. 

The  phenomena  of  propulsion  are  caused  partly  by  the  forced 
attitude  of  the  patient  and  partly  by  the  great  slowness  with 
which  his  movements  are  executed.  When  the  heel  is  once 
raised  from  the  ground  by  contraction  of  the  muscles  of  the  calf, 
the  patient  must  in  walking  balance  himself  on  the  ball  of  the 
foot,  but  in  walking  the  forward  inclination  of  the  body  tends  to 
make  the  line  of  gravity  pass  in  front  of  the  active  leg.  The  posi- 
tion is  to  some  extent  the  same  as  that  assumed  by  a  person  run- 
ning. In  the  latter  the  centre  of  gravity  is  held  well  forwards,  so 
that  the  line  of  gravity  falls  in  front  of  the  foot  of  the  active  leg 
during  the  greater  portion  of  the  time  it  is  maintained  on  the 
ground.     A  healthy  runner,  however,  is  able  to  take  a  rapid 


800  PARALYSIS  AGITANS. 

and  long  stride  with  the  passive  leg,  so  that  by  the  time  it  is 
brought  to  the  ground,  in  order  to  become  active,  it  is  in 
front  of  the  line  of  gravity,  and  the  body  is  thus  kept  from 
falling.  But  it  is  different  in  paralysis  agitans.  The  rigidity 
of  the  muscles  prevents  the  patient  from  taking  a  long  stride, 
while  the  great  slowness  with  which  all  his  movements  are 
executed  renders  it  impossible  for  him  to  plant  the  leg  about  to 
become  active  in  advance  of  the  line  of  gravity.  In  retropul- 
sion  the  line  of  gravity  must  ever  tend  to  fall  behind  the  point 
of  the  foot  of  the  active  leg,  while  the  other  leg  cannot  be  moved 
backwards  with  sufficient  celerity  to  enable  the  patient  to  plant 
it  far  enough  behind  the  retreating  centre  of  gravity  in  order 
to  arrest  the  backward  movement. 

§  885.  Diagnosis. — Paralysis  agitans  is  most  likely  to  be 
mistaken  for  senile  or  toxic  tremor  and  disseminated  sclerosis. 
It  may  be  distinguished  from  senile  tremor  by  the  facts  that  it 
occurs  before  senescence,  and  that  its  tremor  is  of  greater  inten- 
sity ;  the  gait  and  expression  of  paralysis  agitans  are  also  charac- 
teristic. The  tremor  of  mercurial  poisoning  resembles  paralysis 
agitans  more  closely  than  that  of  any  other  form  of  toxic  tremor, 
and  in  distinguishing  between  them  the  history  of  the  case  will 
be  of  much  value.  The  diagnosis  between  paralysis  agitans  and 
disseminated  sclerosis  will  be  described  when  the  latter  disease 
is  under  consideration. 

§  886.  Prognosis.  —  As  far  as  recovery  is  concerned  the 
prognosis  is  absolutely  unfavourable,  but  the  patient  may  live 
for  a  very  long  period.  The  disease  may,  indeed,  last  thirty 
years,  and  the  symptoms  of  the  third  or  terminal  period  may 
linger  on  for  four  or  five  years.  The  sooner  the  muscular 
rigidity  and  paralysis  supervene  the  more  unfavourable  does 
the  prognosis  become. 

§  887.  Treatment. — The  treatment  of  paralysis  agitans  can 
only  be  palliative.  Carbonate  of  iron,  chloride  of  barium, 
hyoscyamus,  and  the  use  of  the  constant  current  or  Pulver- 
macher's  chain,  and  warm  baths  are  the  agents  which  have  been 
vaunted  in  the  treatment  of  the  disease.     Strychnine  has  been 


MULTIPLE   SCLEEOSIS.  801 

praised  by  Trousseau,  but  Charcot  thinks  that,  instead  of  calm- 
ing, it  aggravates  the  tremor.  Ergot  of  rye  and  belladonna  have 
also  been  tried,  but  without  success.  Morphia  and  other  nar- 
cotics are  necessary  adjuncts  of  the  treatment  in  the  later  stages 
of  the  affection  when  the  patient  is  harassed  by  restlessness  and 
sleeplessness,  and  both  chloral  and  bromide  of  potassium  may 
be  of  use  ;  none  of  these  remedies  appears  to  produce  any  action 
beyond  palliating  the  symptoms.  Eulenburg  recommends  the 
subcutaneous  injectioa  of  Fowler's  solution,  and  I  must  say  that 
I  should  have  more  faith  in  arsenic  than  in  any  other  remedy 
with  probably  the  exception  of  phosphorus.  Quinine,  zinc, 
nitrate  of  silver,  and  chloride  of  gold  have  all  been  tried,  but 
without  producing  any  marked  effect  upon  the  disease. 


(II.)    MULTIPLE  SCLEROSIS  OF  THE  BRAIN  AND  SPINAL  CORB 
(Disseminated  or  Insular  Sclerosis). 

§  888.  Definition. — Multiple  sclerosis  is,  as  its  name  implies, 
a  chronic  induration  disseminated  in  patches  in  various  parts 
of  the  nervous  system ;  the  affection  is  characterised  clinically 
by  the  presence,  in  greater  or  lesser  integrity,  of  a  group  of 
symptoms,  the  most  constant  of  which  are  muscular  weakness 
and  tremor  on  voluntary  effort. 

§  889.  History. — Disseminated  sclerosis  was  first  described  by  Cruveil- 
hier  in  bis  "Atlas  de  I'Anatomie  Patbologique,"  1835 — 1842.  Tbe  clinical 
histories  of  two  cases  of  the  disease  are  there  given,  which,  along  with  the 
accompanying  plates  of  the  lesions  found,  leave  no  doubt  as  to  the  natiu'e 
of  the  affection  described.  Carswell  in  1838  accurately  represented  in  his 
"Atlas"  the  lesions  observed,  while  Marshall  Hall  in  1841  described  an 
undoubted  example  of  this  affection.  It  was  that  of  &  man,  aged  28  years, 
suffering  from  tremor  of  the  right  arm  and  leg,  who  had  a  pecuhar  rocking 
motion  of  the  eyes,  and  a  degree  of  stammering  and  defective  articulation. 
In  Germany,  the  disease  was  studied  clinically  by  Frerichs  (1849),  Valentiner 
(1856),  and  Tiirck  (1856) ;  while  its  pathological  anatomy  was  examined  by 
Rokitansky,  Leyden,  Rindfleisch,  and  Zenker.  But  this  singular  affection 
has  been  studied  with  the  greatest  success  in  the  Salpetriere  by  Charcot 
and  his  scholars,  and  our  present  accurate  knowledge  of  the  disease  is 
mainly  owing  to  their  labours.  A  valuable  paper  on  the  subject  has  been 
contributed  by  Moxon  in  this  country,  and  individual  cases  have  been 
recorded  by  many  others. 
ZZ 


802  MULTIPLE   SCLEROSIS. 

§  890.  Etiology. — Hereditary  transmission  has  been  traced 
in  several  recorded  cases  of  multiple  sclerosis,  although  it  is 
always  indirect  rather  than  direct.  Duchenne  and  Erb  have 
reported  cases  of  the  kind.  Frerichs  observed  the  affection 
in  a  brother  and  sister,  and  Dreschfeld  described  two  exquisite 
examples  iu  brothers. 

According  to  Charcot  the  female  is  more  frequently  affected 
than  the  male  sex,  but  the  statistics  of  others  do  not  bear  out 
this  conclusion.  Multiple  sclerosis  is  commonly  observed  in 
youth  and  middle  age,  and  usually  makes  its  appearance  during 
the  second  and  third  decades  of  life,  and  probably  never  after 
45  years  of  age.  In  a  large  proportion  of  the  cases  recorded 
in  England,  children  under  ten  years  of  age  have  been  the 
subjects. 

The  exciting  causes  are  exposure  to  cold  and  damp,  excessive 
mental  or  bodily  exertion,  profound  emotional  disturbances, 
and  traumatic  influences,  as  blows  on  the  head  and  concussion 
from  railway  accidents. 

§  .891  Symptoms. — Multiple  sclerosis  has  been  divided  by 
Charcot  into  three  varieties :  (1)  The  cerebrospinal,  (2)  the 
cerebral,  and  (3)  the  spinal  form.  Of  these  the  cerebro-spinal 
form  is  by  far  the  most  frequent  and  important. 

(1)  The  Cerebro- Spinal  Form.  —  This  form  of  multiple 
sclerosis,  as  a  rule,  develops  gradually  and  insidiously,  but 
occasionally  abruptly.  In  cases  the  development  of  which  is 
gradual  the  initial  symptoms  are  very  obscure,  and  may  be 
referred  either  to  the  spinal  cord  or  brain.  The  spinal  symp- 
toms which  usher  in  the  disease  consist  of  paresis  of  the  lower 
extremities  with  a  slow  and  trembling  gait,  or  ataxia  with 
various  parses thesise,  neuralgic  pains,  other  disturbances  of  sen- 
sibility in  the  limbs,  and  cardialgic  attacks  accompanied  by 
urgent  vomitiog.  The  more  usual  cerebral  symptoms  observed 
in  the  beginning  of  the  disease  are  vertigo,  headache,  staggering 
gait,  tremors  on  voluntary  effort,  impairment  of  speech,  vision 
or  hearing,  paresis  of  the  muscles  supplied  by  one  or  more  of 
the  cranial  motor  nerves,  and  various  psychical  disturbances. 
When  the  disease  begins  abruptly,  the  symptoms  are  ushered 


MULTIPLE   SCLEROSIS,  803 

in  by  a  convulsive  or  apoplectiform  attack,  followed  by  diplopia, 
amblyopia,  or  nystagmus,  and  disturbances  of  speech. 

The  first  motor  symptom  to  attract  attention  is  usually 
paresis  or  paralysis  of  certain  muscular  groups.  Weakness 
generally  begins  in  one  leg,  and  subsequently  extends  to  the 
other  leg  and  to  the  arms,  but  the  order  in  which  the  paralysis 
of  the  different  muscular  groups  is  developed  presents  every 
imaginable  combination. 

The  gait  is  usually  of  the  spastic  variety,  muscular  contrac- 
tures set  in,  and  the  legs  are  held  like  rigid  bars  in  the  position 
of  extension  and  adduction,  just  as  in  primary  lateral  sclerosis. 
In  the  later  stages  of  the  disease  flexion  of  the  different  seg- 
ments of  the  lower  extremities  may  predominate  over  extension . 
The  paralysis  rarely  becomes  so  well  marked  in  the  upper  as  in 
the  lower  extremities.  When  the  upper  extremities  are,  how- 
ever, affected  with  paralysis  and  contracture,  they  are  main- 
tained in  a  position  of  forced  extension,  and  closely  applied  to 
the  sides  of  the  body.  The  affection  sometimes  begins  with 
ataxia,  but  in  these  cases  it  may  often  be  noticed  that  charac- 
teristic symptoms  of  true  locomotor  ataxia  are  absent,  while 
others  are  present  which  do  not  usually  belong  to  it.  In  a 
patient  under  my  care  at  present,  for  instance,  the  symptoms 
when  I  first  saw  him,  upwards  of  two  years  ago,  were  paralysis 
of  both  sixth  nerves,  and  an  ataxic  gait.  But  the  gait,  differing 
from  that  of  locomotor  ataxia,  was  somewhat  reeling,  although 
not  sufficiently  so  to  be  attributed  to  cerebellar  disease,  there 
were  no  lancinating  pains  in  the  extremities,  and  the  patellar- 
tendon  reflex  was  exaggerated  in  both  legs.  The  patient  is  now 
suffering  from  the  same  ataxic  gait,  the  characteristic  tremors  of 
multiple  sclerosis,  slight  nystagmus,  and  scanning  speech,  while 
the  paralysis  of  the  external  recti  muscles  has  disappeared. 

Intermittent  m^j^scular  tremor  constitutes  one  of  the  most 
characteristic  symptoms  of  this  affection,  although  it  has  been 
found  absent  in  a  few  isolated  cases.  This  tremor  appears 
almost  exclusively  during  voluntary  movements,  and  disappears 
during  repose.  So  long  as  the  patient  remains  seated  quietly 
the  tremor  is  either  entirely  absent,  or  at  most  there  is  only  a 
trifling  shaking  movement  of  the  head,  or  a  slight  oscillation  ot 
the  trunk.     As  soon,  however,  as  he  attempts  to  seize  anything 


804  MULTIPLE  SCLEROSIS. 

with  his  hand  the  tremor  begins,  and  increases  in  violence  in 
proportion  to  the  effort  made  to  execute  the  movement.  Several 
devices  may  be  used  in  order  to  bring  into  prominence  the 
characteristic  tremor  of  multiple  sclerosis,  such  as  asking  the 
patient  to  seize  small  objects  with  his  fingers  or  to  stretch  out 
his  arms  horizontally  before  him. 

The  tremor  of  this  affection  differs  from  that  of  paralysis 
agitans,  not  only  in  being  intermittent  instead  of  continuous, 
but  also  in  having  a  much  wider  sweep  than  that  of  the  latter 
affection.  It  holds  an  intermediate  position  between  the  exten- 
sive jerking  movements  of  chorea,  and  the  small  and  frequent 
oscillations  of  paralysis  agitans.  The  true  characteristics  of 
the  tremor  of  multiple  sclerosis  is  best  elicited  by  asking  the 
patient  to  convey  a  glass  of  water  to  his  mouth.  As  the  glass 
is  being  carried  to  the  mouth  it  oscillates  from  side  to  side  in 
the  patient's  hand,  these  oscillations  appearing  to  increase  in 
extent  and  frequency  as  the  mouth  is  approached.  In  aggra- 
vated cases  the  contents  of  the  glass  are  spilt  in  every  direction; 
but  in  milder  cases  the  patient  is  able,  moving  his  head  down- 
wards in  order  to  meet  the  glass,  to  apply  it  to  his  lips,  and 
then  the  trunk,  head,  and  arms  begin  to  tremble  violently,  so 
that  the  edge  of  the  glass  rattles  against  the  teeth,  and  the 
contents  are  spluttered  over  the  patient's  face.  When  the 
patient  rises  and  attempts  to  walk  the  tremor  involves  the 
entire  body,  which  may  be  shaken  with  such  violence  that  he 
is  unable  to  proceed  or  even  to  remain  standing.  As  soon  as 
the  voluntary  effort  is  relaxed  the  tremor  diminishes,  and  as 
long  as  the  patient  is  in  the  recumbent  posture  no  trace  of  it 
can  usually  be  detected ;  occasionally  the  tremor  has  been 
known  to  persist  during  repose. 

The  sensory  disturbances  are  somewhat  variable  and  not 
always  well  marked.  They  may  assume  the  form  of  facial 
neuralgia,  lancinating  or  diffused  pains  in  the  extremities, 
hypereesthesia  or  anaesthesia  of  variable  distribution,  girdle 
pains,  and  various  parsesthesise  felt  in  different  parts  of  the 
body,  the  latter  being  the  most  frequent  of  all  the  sensory 
disorders. 

The  reflex  actions  are  variously  affected  in  different  cases. 
The   cutaneous  reflexes  remain  for  a   long  time   unaffected ; 


MULTIPLE   SCLEROSIS.  805 

but  the  deep  reflexes  are  usually  exaggerated,  especially  in  the 
lower  extremities.  In  consequence  of  the  increase  of  the  tendon- 
reflexes  in  the  lower  extremities,  the  knee-phenomenon  and 
ankle  clonus  are  usually  exaggerated,  and  the  limbs  may  be 
thrown  into  the  state  of  trembling  named  spinal  epilepsy.  This 
condition  must,  however,  be  carefully  distinguished  from  the 
characteristic  tremor  of  multiple  sclerosis. 

Trophic  disturbances  are  generally  wanting  for  a  long  time, 
but  in  the  later  stages  various  nutritive  disorders  usually  make 
their  appearance.  The  sclerotic  nodules  may  encroach  on  the 
anterior  grey  horns  of  the  spinal  cord,  and  then  muscular  atrophy 
results  as  in  progressive  muscular  atrophy.  Muscular  atrophy 
may  present  itself  in  the  upper  or  lower  extremities,  neck,  face, 
tongue,  or  indeed  in  any  part  of  the  body.  The  electrical  reac- 
tions of  the  nerves  and  muscles  remain  normal  until  the  muscular 
atrophy  begins,  and  then  the  electric  irritability  of  both  becomes 
gradually  diminished. 

During  the  terminal  period  of  the  disease  bed-sores  appear 
over  the  sacrum  and  other  parts  subjected  to  pressure,  and 
general  nutrition  fails. 

The  bladder  and  rectum,  as  a  rule,  remain  unaffected  for  a 
comparatively  long  time,  but  their  functions  are  ultimately  in- 
terfered with  as  in  chronic  myelitis.  The  disorders  of  the  sexual 
functions  are  somewhat  variable.  In  some  patients  sexual  desire 
appears  to  be  increased  at  an  early  period  of  the  disease,  while 
in  others  it  is  completely  abolished.  In  the  majority  of  cases 
the  sexual  functions  remain  normal  for  a  comparatively  long 
time. 

Bulbar  Symptoms. — Some  of  the  phenomena  caused  by 
implication  of  the  pons  and  medulla  oblongata  in  the  morbid 
process  are  amongst  the  most  important  and  characteristic 
symptoms  of  the  disease.  The  speech  is  slow  and  hesitating, 
while  each  syllable  is  separately  pronounced,  presenting  a  mode 
of  articulation  which  has  been  named  the  syllabic  or  scanning. 
The  voice  is  weak,  low,  sometimes  whispering,  and  monotonous, 
while  it  breaks  readily  when  forced  efforts  are  made.  Laryngo- 
scopic  examination  shows  that  the  vocal  cords  move  normally, 
but  their  tension  is  diminished  and  frequently  changes  (Leube). 
The  acts  of  laughing  and  crying  are  often  represented  by  peculiar 


806  MULTIPLE   SCLEROSIS. 

noisy  inspirations.  After  a  time  symptoms  of  true  bulbar 
paralysis  supervene,  the  movements  of  the  lips  and  tongue  are 
impaired,  and  by-and-by  mastication  and  deglutition  become 
increasingly  difficult,  the  velum  palati  is  paralysed,  speech 
becomes  inarticulate,  and  the  mouth  remains  permanently 
paralysed,  while  the  saliva  dribbles  out. 

Diplopia  with  strabismus  is  a  not  unfrequent  symptom, 
although  it  may  subsequently  disappear  as  in  locomotor  ataxia. 

Nystagmus  is,  however,  the  most  important  of  all  the  ocular 
symptoms,  being  present,  according  to  Charcot,  in  about  half  the 
cases.  The  movements  of  the  eyeballs  may  be  persistent  or 
occur  only  during  forced  accommodation,  or  when  movements 
are  performed  by  the  extremities.  At  other  times  the  nystagmus 
may  not  be  apparent  during  the  ordinary  movements  of  the 
eyeballs,  but  when  the  patient  is  asked  to  look  upwards  and 
outwards  so  as  to  strain  the  ocular  muscles,  slight  oscillatory 
movements  may  be  observed. 

Amblyopia  is  not  unfrequently  observed.  It  consists  of  a 
progressive  weakness  of  sight,  accompanied  by  colour  blindness 
and  restriction  of  the  field  of  vision,  and  may  increase  to  com- 
plete blindness.  The  development  of  amblyopia  is  sometimes 
preceded  by  photopsia;  the  optic  discs  may  be  normal,  partially 
diseased,  or  the  subjects  of  white  atrophy. 

The  senses  of  smell,  taste,  and  hearing  are  impaired  in  some 
cases,  but  these  disorders  are  rare. 

Psychical  disturbances  are  always  observed  in  multiple 
cerebro-spinal  sclerosis.  They  consist  of  mental  irritability, 
emotional  excitability  causing  the  patient  to  laugh  or  to  shed 
tears  without  apparent  motive,  and  impairment  of  memory  and 
intelligence.  At  other  times  the  mental  disorder  assumes  the 
form  of  distinct  unsoundness  of  mind.  In  such  cases  there  may 
be  melancholia,  monomania,  with  ideas  of  persecution  or  of 
grandeur,  and  the  patient  may  fall  into  a  state  of  complete 
dementia. 

In  the  course  of  the  disease,  the  patient  suffers  from  attacks 
of  vertigo.  This  symptom  usuall}''  comes  on  at  an  early  period, 
and  continues  to  distress  the  patient  throughout.  The  patients 
feel  as  if  they  themselves  were  being  turned  round,  or  as  if 


MULTIPLE  SCLEROSIS.  807 

surrounding  objects  were  whirling  round  them.     They  suffer 
greatly  from  sleeplessness  and  violent  headache. 

Apoplectiform  or  epileptiform  seizures  have  been  observed 
in  a  small  number  of  cases  ;  they  are  apparently  analogous  to 
the  apoplectiform  attacks,  which  occur  in  general  paralysis 
of  the  insane.  They  are  characterised  by  the  development 
of  grave  cerebral  symptoms,  and  are  accompanied  by  a 
considerable  elevation  of  temperature.  After  slight  premoni- 
tory symptoms,  such  as  a  feeling  of  pressure  in  the  head,  there 
is  a  partial  loss  of  consciousness,  which  in  a  few  hours  may 
develop  into  coma.  The  face  is  red  and  hot,  the  pulse  is  quick, 
and  the  temperature  of  the  body  rises  to  104°  F.  or  105°  F.  In 
some  cases  the  loss  of  consciousness  is  accompanied  by  unilateral 
convulsions — epileptiform  attacks;  while  in  other  cases  there 
are  no  convulsions — apoplectiform  attacks.  In  most  cases  hemi- 
plegia with  muscular  flaccidity,  and  on  rare  occasions  rigidity,  is 
present  from  the  outset  of  the  seizure.  After  one  or  two  days 
the  temperature  falls,  the  patient  sinks  into  a  quiet  sleep  from 
which  he  may  be  readily  roused,  and  he  feels,  on  awaking, 
comparatively  well.  Hemiplegia,  however,  persists  for  a  few 
days  longer  and  then  gradually  disappears.  These  attacks  may 
be  repeated  several  times  in  the  course  of  the  disease,  recurring 
in  some  cases  every  few  months ;  but  each  is  followed  by  an 
aggravation  of  the  general  symptoms,  and  death  sometimes 
oocurs  during  an  attack. 

(2)  Cerebral  Multiple  Sclerosis. — In  this  form  of  the  disease, 
which  is  rarely  observed,  the  psychical  disturbances  are  pre- 
dominant. The  tremor  is  said  to  precede  the  paralytic  mani- 
festations, but  in  other  respects  the  course  of  the  affection  does 
not  differ  greatly  from  the  cerebro-spinal  variety. 

(3)  Spinal  Multiple  Sclerosis. — The  spinal  form  of  the  affec- 
tion is  characterised  by  the  absence  of  the  cerebral  symptoms, 
particularly  nystagmus,  tremor  on  voluntary  effort,  vertigo, 
apoplectiform  attacks,  and  psychical  disturbances.  The  symp- 
toms of  the  spinal  form  of  multiple  sclerosis  often  simulate 
those  of  primary  lateral  sclerosis,  although  in  the  former  some 
additional  symptoms  are  usually  present.  In  other  cases  they 
simulate  locomotor  ataxia,  but  in  multiple  sclerosis  symptoms 
are  usually  present  which  form  no  part  of  the  former. 


808  MULTIPLE   SCLEROSIS. 

§  892.  Course,  Duration,  and  Terminations. — The  course  of 
multiple  sclerosis  is  divided  by  Charcot  into  three  stages  : — 

The  Jirst  stage  extends  from  the  beginning  of  the  disease  up 
to  the  appearance  of  marked  paralysis  with  contractures.  This 
stage  may  last  from  two  to  six  years,  or  longer.  Its  develop- 
ment is  generally  slow.  It  sometimes  begins  with  cephalic 
symptoms,  as  headache,  vertigo,  and  unsteady  gait ;  but  more 
usually  with  spinal  symptoms,  as  paresis  of  the  lower  extremities, 
and  in  such  cases  the  nature  of  the  disease  remains  doubtful 
until  the  appearance  of  the  characteristic  tremor  clears  up  the 
diagnosis. 

In  other  cases  the  development  of  the  disease  is  more  rapid. 
It  begins  by  an  apoplectiform  attack,  or  gastralgic  disturbances, 
while  paralyses,  disorders  of  co-ordination,  tremor,  and  other 
symptoms  are  superadded  in  quick  succession.  The  progress  of 
this  stage  is  often  interrupted  by  remissions  or  improvements, 
but  the  nature  of  the  disease  is  essentially  progressive.  The 
patients  become  more  and  more  helpless,  complete  paraplegia 
is  developed,  the  legs  being  maintained  in  a  condition  of  rigid 
extension  and  adduction  ;  tremor  deprives  them  of  the  use  of 
the  hands,  and  the  intellectual  power  becomes  more  and  more 
impaired. 

The  second  stage  of  the  disease  is  now  developed ;  it  lasts 
from  four  to  six  or  more  years.  During  this  period  the  disease 
remains  more  or  less  stationary ;  the  general  nutrition  is  but 
little  impaired. 

The  third  stage  is  characterised  by  impairment  of  general 
nutrition  and  the  appearance  of  symptoms  indicative  of  ex- 
haustion. The  patient  loses  his  appetite  and  becomes  emaciated ; 
the  bladder  is  paralysed,  and  cystitis  and  bed-sores  occur,  leading 
to  pysemia,  marasmus,  and  death. 

The  increasing  bulbar  symptoms  may  threaten  life  in  another 
way,  while  it  is  not  unfrequently  cut  short  by  intercurrent 
disease,  as  pneumonia,  pleurisy,  or  pulmonary  consumption. 

Some  cases  have  terminated  fatally  in  from  one  to  two  years 
from  the  commencement,  but  such  cases  are  rare.  The  average 
duration  is  from  five  to  ten  years,  but  individual  cases  have 
lived  much  longer. 

The  termination  of  the  disease  is  always  in  death.     During 


MULTIPLE   SCLEROSIS.  809 

the  first  stage  a  partial  amelioration  of  the  symptoms  may- 
occur,  either  spontaneously  or  under  treatment,  which  may 
lead  the  patient  and  his  friends  to  hope  for  recovery.  The 
improvement  is,  however,  deceptive,  for  the  symptoms  always 
return  and  ultimately  prove  fatal. 

§  893.  Morbid  Anatomy. — The  morbid  alterations  in  mul- 
tiple sclerosis  appear  in  more  or  less  numerous  spots  or 
nodules,  which  are  scattered  in  greater  or  lesser  number 
throughout  the  spinal  cord,  medulla  oblongata,  pons  varolii, 
cerebellum,  and  cerebrum. 

The  individual  nodules,  when  near  the  surface  of  the  spinal 
cord,  may  be  seen  through  the  pia  mater  as  brown  or  amber 
stains,  and  in  aggravated  cases  the  entire  surface  of  the  cord  may 
be  studded  with  greyish  spots.  Each  spot  is,  as  a  rule,  sharply 
defined  from  the  surrounding  tissues  and  slightly  elevated 
above  the  surface  of  the  cord,  but  it  is  occasionally  atrophic  and 
depressed  or  on  a  level  with  the  normal  portions.  On  transverse 
section  the  nodules  appear  grey  or  greyish-yellow,  and  when 
exposed  to  the  air  change  to  a  salmon  colour;  they  are  trans- 
lucent or  opaque,  irregular  or  oval  in  shape,  generally  isolated 
and  circumscribed,  but  occasionally  confluent,  and  are  in  consis- 
tence dense,  tough,  even  cartilaginous,  but  rarely  semi-fluid  and 
gelatinous.  These  nodules  vary  from  the  size  of  a  hemp-seed 
to  that  of  a  bean  in  the  spinal  cord,  but  they  often  become 
confluent  and  consequently  appear  to  attain  a  much  larger  size 
in  the  brain.  The  distribution  of  the  nodules  in  the  spinal 
cord  is  subject  to  great  variations.  On  making  successive 
transverse  sections  of  the  cord  the  nodules  will  appear  in  one 
or  both  of  the  lateral  columns  at  one  level,  in  the  posterior 
columns  at  another,  and  in  the  grey  substance  at  a  third,  while 
the  nodule  occupies  the  greater  part  of  the  area  of  the  section 
at  certain  levels.  The  number  of  nodules  which  are  present  is 
variable,  a  few  only  being  observed  in  some  cases,  while  in  others 
huodreds  may  be  counted. 

The  cerebral  hemispheres  usually  contain  a  large  number  of 
nodules,  their  favourite  sites  being  the  white  substance  of 
the  centrum  ovale,  septum  lucidum,  corpus  callosum,  basal 
ganglia,  and  walls  of  the  lateral  ventricles.     The  cerebellum 


810  MULTIPLE   SCLEROSIS, 

generally  contains  a  few  of  them,  these  being  generally  found 
in  the  central  white  substance.  The  convolutions  of  the  cortex 
of  the  brain,  and  the  cortex  of  the  cerebellum,  are  usually 
exempted.  A  considerable  number  of  nodules  are  generally 
found  in  the  pons,  medulla  oblongata,  and  peduncles  of  the 
cerebrum  and  cerebellum. 

The  nerves  themselves  may  be  affected  by  patches  of  sclerosis  ; 
the  cranial  nerves  in  their  passage  along  the  base  of  the  skull 
are  specially  liable  to  be  affected.  The  anterior  and  posterior 
roots  of  the  spinal  nerves  have  been  found  diseased. 

The  membranes  of  the  brain  and  spinal  cord  are  frequently 
normal,  but  at  other  times  they  present  evidences  of  hypersemia 
and  chronic  inflammation.  The  cerebro-spinal  fluid  is  generally 
increased,  often  cloudy,  and  the  ventricles  are  dilated.  Bed- 
sores, pyelo-nephritis,  and  evidences  of  pyaemia  or  of  an  inter- 
current disease  are  usually  observed  at  the  autopsy. 

On  microscopical  examination  the  sclerosed  patch  is  found  to 
present  the  usual  appearances  of  chronic  interstitial  myelitis. 
The  trabeculas  of  the  neuroglia  are  thickened,  the  nuclei  are 
swollen  and  increased  in  number,  while  Deiter's  cells  are  nume- 
rous, large,  and  sharply-defined.  The  medullary  sheath  of  the 
nerve -fibres  is  gradually  destroyed,  but  the  axis-cylinder  per- 
sists for  a  long  time.  Ultimately  the  nodule  consists  of  a  wavy 
fibrillated  connective  tissue,  in  which  all  trace  of  nerve  structure 
is  lost.  The  walls  of  the  vessels  are  thickened  and  the  lumen 
is  diminished,  while  the  adventitia  becomes  blended  with  the 
connective  tissue,  and  the  surrounding  lymph -channels  are 
obliterated.  An  infiltration  of  fat  into  the  lymph -channels 
surrounding  the  vessels  has  been  described,  but  this  appeara,nce 
is  probably  produced  by  methods  of  histological  preparation. 
If  the  sclerosis  extend  into  the  grey  substance,  the  ganglion 
cells  become  degenerated  and  atrophied. 

§  894.  Morhid  Physiology. — Multiple  sclerosis  is  a  compound 
affection,  and  the  implication  of  several  of  the  functional  systems 
of  the  spinal  cord  affords  a  read}''  explanation  of  a  large  number 
of  the  symptoms. 

The  paresis,  contractures,  excess  of  the  tendon-reflexes,  and 
the  phenomena  grouped  under  the  name  of  spinal  epilepsy  are 


MULTIPLE   SCLEROSIS.  811 

caused  by  implication  of  the  lateral  columns ;  the  ataxic  symp- 
toms are  produced  by  the  formation  of  nodules  in  the  posterior 
columns ;  muscular  atrophy  by  invasion  of  the  anterior  cornua ; 
while  impairment  of  speech,  disturbances  of  respiration,  diffi- 
culty of  deglutition,  and  other  bulbar  symptoms  are  caused  by 
disease  of  the  nuclei  in  the  medulla  oblongata  and  pons.  The 
nystagmus  is  caused  probably  by  the  presence  of  nodules  in  the 
corpora  quadrigemina  or  peduncles  of  the  cerebellum ;  whilst 
impairment  of  smell  and  taste,  diplopia,  facial  and  other  para- 
lyses, and  amblyopia  are  often  produced  by  sclerotic  patches  on 
the  cranial  nerves  themselves  as  they  pass  along  the  base  of  the 
skull.  Vertigo  may  be  occasionally  due  to  an  existing  diplopia, 
but  it  is  generally  the  result  of  nodules  in  the  cerebellum. 

The  psychical  disturbances  are  doubtless  caused  by  the 
development  of  nodules  in  the  hemispheres  of  the  brain. 

The  apoplectiform  attacks  are  difficult  to  explain,  but  the 
most  usual  explanation  is  that  they  are  occasioned  by  attacks 
of  cerebral  congestion.  This  opinion  is,  however,  opposed  by 
Charcot,  who  was  unable  to  discover  any  evidence  of  congestion 
or  oedema  of  the  brain  in  cases  which  terminated  fatally.  He 
thinks  that  these  attacks  are  only  observed  in  cases  in  which 
the  pons  and  medulla  oblongata  are  diseased. 

The  cause  of  the  characteristic  tremor  of  multiple  sclerosis  is 
very  obscure.  Charcot  attributes  it  to  the  long  persistence  of 
the  axis-cylinders  in  the  nodules  of  sclerosis.  Conduction 
through  these  may  still  take  place,  although  when  once  the 
medullary  sheath  is  destroyed  the  conduction  will  be  so  retarded 
that  the  impulses  from  the  cortex  do  not  pass  in  a  sufficiently 
quick  succession  to  cause  a  continuous  contraction.  On  the 
other  hand,  it  is  asserted  that  in  purely  spinal  cases  the  charac- 
teristic tremors  are  absent  (Hammond,  Ebstein),  and  that  they 
are  never  present  unless  the  pons  and  the  parts  of  the  brain 
situated  in  front  of  it  are  affected  (Ordenstein),  Erb  examined 
twenty-two  recent  cases  with  the  view  of  deciding  this  question. 
In  all  the  cases  in  which  the  tremors  were  present  during  life, 
the  pons,  medulla  oblongata,  crura  cerebri,  and  other  parts  of 
the  brain  were  involved  in  the  sclerosis ;  while  in  the  cases  in 
which  there  were  no  tremors  the  nodules  were  absent  or  only 


812  MULTIPLE   SCLEROSIS. 

present  in  small  numbers  in  the  pons,  medulla  oblongata,  and 
cerebellum,  although  other  parts  of  the  brain  were  affected. 

§  895.  Diagnosis. — Multiple  cerebro-spinal  sclerosis  and  para- 
lysis agitans  have  only  been  distinguished  from  one  another  in 
recent  years.  The  tremor  of  paralysis  consists  of  fine  rapid  oscil- 
lations ;  it  persists  during  repose,  may  be  temporarily  arrested 
by  a  voluntary  effort,  and  never  implicates  the  muscles  of  the 
head  ;  while  the  tremor  of  multiple  sclerosis  is  more  extensive, 
ceases  during  rest,  is  excited  or  aggravated  by  voluntary  move- 
ments, and  invariably  implicates  the  muscles  of  the  head.  Para- 
lysis agitans  is  a  disease  of  advanced  age,  and  multiple  sclerosis 
of  youth  and  middle  age.  In  the  former  paralysis  is  not 
developed  until  long  after  the  appearance  of  tremor;  while  in 
multiple  sclerosis  the  paralysis  precedes  or  soon  follows  the 
tremor.  The  cerebral  symptoms  of  multiple  sclerosis  already 
described  are  wanting  in  paralysis  agitans. 

The  spinal  form  of  multiple  sclerosis  may  be  mistaken  for 
locomotor  ataxia ;  but  in  the  former  disease  the  ataxic  gait 
may  be  associated  with  excess  of  tendon-reflex,  tremor,  early 
appearance  of  paralysis,  scanning  speech,  nystagmus,  or  other 
symptoms  which  do  not  belong  to  locomotor  ataxia. 

The  cases  of  hereditary  ataxia  described  by  Friedreich  are, 
owing  to  the  presence  of  nystagmus,  very  liable  to  be  mistaken 
for  multiple  sclerosis  ;  but  in  the  latter  early  paralysis,  con- 
tractures, excess  of  tendon-reflex,  scanning  speech  and  other 
bulbar  symptoms,  and  apoplectiform  attacks  and  other  cerebral 
disturbances  are  absent.  The  spinal  form  of  multiple  sclerosis 
is  most  liable  to  be  mistaken  for  primary  lateral  sclerosis,  and 
in  some  cases  a  diagnosis  is  impossible.  If,  in  addition  to  the 
well-known  and  classical  symptoms  of  lateral  sclerosis,  other 
symptoms,  as  scanning  speech  and  tremor,  be  present,  then 
multiple  sclerosis  ought  to  be  suspected. 

When  the  grey  substance  of  the  spinal  cord  and  medulla 
oblongata  is  involved,  multiple  sclerosis  may  be  mistaken  for 
progressive  muscular  atrophy,  progressive  bulbar  paralysis,  or 
amyotrophic  lateral  sclerosis ;  but  the  course  and  symptoms  of 
multiple  sclerosis  render  it  easily  distinguishable  from  the  other 
affections. 


MULTIPLE   SCLEROSIS,  813 

Certain  affections  accompanied  by  trembling,  as  senile,  mer- 
curial, and  saturnine  tremor,  bear  some  resemblance  to 
multiple  sclerosis;  but  the  diagnosis,  as  a  rule,  presents  no 
difficulty.  I  have,  however,  seen  a  case  of  mercurial  tremor 
which  could  only  be  distinguished  from  a  moderately  ad- 
vanced case  of  multiple  sclerosis,  by  the  history  of  the  case 
and  by  the  beneficial  effects  of  treatment.  Tremor  in  hysterical 
subjects  may  likewise  be  mistaken  for  that  of  multiple  scle- 
rosis ;  in  the  former  the  tremor  persists  during  repose  provided 
the  patient  be  conscious  of  being  observed,  it  may  disappear  for 
days  or  weeks  and  then  recur,  and  general  hysterical  symp- 
toms are  usually  present.  The  disorderly  movements  of  chorea 
differ  considerably  from  the  tremor  of  multiple  sclerosis,  but  the 
diagnosis  is  not  always  easy  when,  as  may  occasionally  happen, 
choreiform  movements  complicate  those  proper  to  multiple 
sclerosis. 

§  896.  Prognosis. — The  prognosis  is  always  unfavourable, 
but  it  must  be  remembered  that  the  course  of  the  disease  is 
often  interrupted  by  remissions  and  partial  ameliorations  of  the 
symptoms.  The  prognosis  in  each  case  will  depend  upon  the 
presence  or  absence  of  bulbar  symptoms,  apoplectiform  attacks, 
cystitis,  bed-sores,  and  other  symptoms  which  are  known  to 
threaten  life. 

§  897.  Treatment. — The  treatment  of  multiple  sclerosis  is 
essentially  the  same  as  that  of  chronic  myelitis,  our  therapeutic 
means  being  even  more  limited  in  the  former  than  in  the  latter 
disease.  Arsenic,  belladonna,  bromide  of  potassium,  ergot,  and 
strychnine  have  proved  useless  in  the  hands  of  Charcot,  while 
the  disease  was  aggravated  by  chloride  of  gold  and  phosphate 
of  zinc.  Nitrate  of  silver  appeared  to  produce  a  favourable 
effect,  which,  however,  was  maintained  only  for  a  short  period. 
Hammond  recommends  three-quarters  of  a  grain  of  chloride  of 
barium  three  times  a  day.  The  most  promising  treatment 
appears  to  be  the  persistent  application  of  the  galvanic  current 
to  the  spine,  hydropathy,  nitrate  of  silver,  phosphorus,  cod-liver 
oil,  and  nourishing  but  unstimulating  diet. 


814 


CHAPTER    II. 


CHOREA,  AND    MENIERE'S    DISEASE, 


(I.)  CHOREA. 
Two  forms  of  chorea  are  often  described,  named  respectively 
chorea  major  and  chorea  minor,  but  the  former  is  only  an 
aggravated  form  of  hysteria,  and  consequently  the  latter  alone 
will  here  be  described  under  the  name  of  chorea.  It  is  a  disease 
which  chiefly  attacks  children,  and  is  characterised  by  irregular 
clonic  spasms  of  certain  groups  of  voluntary  muscles. 

§  898.  Etiology. — Heredity  plays  an  important  part  in  the 
production  of  chorea,  but  the  transmission  is  probably  always 
indirect.  The  patient  may  inherit  either  a  susceptible  nervous 
system,  or  the  rheumatic  diathesis — rheumatism  being  one  of 
the  most  frequent  and  important  causes  of  the  disease.  Age 
is  an  important  predisposing  cause  of  chorea,  the  disease 
generally  occurring  during  the  period  of  bodily  development. 
Isolated  cases  of  the  affection  have  been  observed  in  infants 
at  the  breast,  while  it  is  not  uncommon  in  young  women.  S^e 
states  that  three-fourths  of  the  cases  observed  in  the  Children's 
Hospital  in  Paris  occurred  in  girls. 

Everything  which  augments  the  excitability  of  the  nervous 
system  during  the  period  of  sexual  development,  as  premature 
excitement  of  the  sexual  passion,  onanism,  or  any  undue 
emotional  disturbance,  increases  the  tendency  to  chorea.  The 
most  usual  predisposing  causes  of  the  affection  in  adults  are 
pregnancy,  menstrual  disorders,  and  chlorosis. 

Very  little  is  known  with  regard  to  the  geographical  distri- 
bution of  the  disease,  or  the  influence  exerted  by  the  different 


CHOKEA.  815 

seasons  and  atmospheric  changes  in  its  production.  That  some 
causal  relationship  exists  between  articular  rheumatism  and 
chorea  has  been  known  since  the  beginning  of  the  century, 
but  the  true  nature  of  this  relationship  is  not  yet  accurately 
ascertained.  The  frequent  occurrence  of  cardiac  murmurs  in 
chorea  was  noticed  by  Addison  and  subsequently  by  Todd.  Out 
of  299  cases  collected  by  Hughes  and  Brown,  there  were  104 
whose  history  could  be  carefully  ascertained,  and  of  these  only 
15  had  not  suffered  from  rheumatism  or  had  not  developed 
cardiac  murmur.  Out  of  128  patients  suffering  from  chorea 
See  found  64  who  had  suffered  from  articular  rheumatism. 
Chorea  occurs  frequently  after  scarlatina,  a  fact  which  may 
probably  be  explained  by  the  frequency  with  which  the  latter 
is  followed  by  rheumatism. 

The  relationship  between  pregnancy  and  chorea  is  very 
obscure,  inasmuch  as  it  is  only  in  a  small  number  of  cases  that 
the  attack  has  been  preceded  by  rheumatism  or  endocarditis. 
Chorea  occurs  most  frequently  during  first  pregnancies,  although 
it  is  sometimes  repeated  in  the  same  patient  in  subsequent 
pregnancies,  and  the  majority  of  those  affected  are  from  twenty 
to  twenty-three  years  of  age.  It  appears  more  frequently  during 
the  first  than  the  second  half  of  pregnancy,  but  sometimes  it 
begins  in  the  later  months  and  may  continue  up  to  the  time  of 
delivery  or  even  beyond  it. 

Of  the  exciting  causes  of  chorea  the  most  frequent  and 
important  are  emotional  disturbances,  such  as  fright,  sorrow, 
and  discontent.  Hysterical  girls  and  those  who  are  strongly 
predisposed  to  chorea,  or  who  have  already  suffered  from  an 
attack,  may  acquire  the  disease  by  imitation  of  those  suffering 
from  it. 

§  899.  Symptoms. — The  development  of  the  characteristic 
phenomena  of  chorea  is  generally  preceded  by  various  premoni- 
tory symptoms  for  a  variable  period  of  days  or  weeks.  The 
most  usual  of  these  are  afforded  by  changes  in  the  character 
and  disposition  of  the  patient,  who  becomes  forgetful,  inatten- 
tive, fretful,  and  discontented  or  apathetic,  while  the  intellectual 
powers  are  impaired.  The  spasmodic  movements  may  in  some 
cases  be  preceded  by  paralytic  phenomena.     A  case  under  my 


816  CHOREA. 

care  at  the  Manchester  Southern  Hospital  was  admitted  as  one 
of  hemiplegia,  and  it  was  only  two  days  after  admission  that 
the  characteristic  choreic  movements  made  their  appearance. 
The  irregular  spasmodic  muscular  contractions  of  chorea  are, 
indeed,  not  unfrequently  ushered  in  by  a  slight  dragging  of  one 
of  the  lower  extremities,  with  a  tendency  to  walk  in  a  curved 
line  and  liability  to  let  objects  fall  from  the  hand.  These 
manifestations  of  the  approaching  disease  are  probably  due,  in 
some  degree,  to  irregular  muscular  contractions,  but  are  largely 
dependent  upon  muscular  weakness.  The  characteristic  choreic 
movements  generally  begin  in  the  small  muscles  of  the  face 
and  in  those  of  a  hand.  They  consist  at  first  of  grimaces  and 
other  contortions  of  the  face,  and  slight  jerking  movements  of 
the  fingers  and  at  the  wrist  joint,  with  pronation  of  the  fore- 
arm, when  the  patient  is  conscious  of  being  observed  or  is 
excited  from  any  other  cause ;  these  soon  increase  in  intensity 
and  persist  during  repose. 

The  irregular  contractions  soon  extend  so  as  to  involve  all 
the  voluntary  muscles,  when  the  affection  may  be  called 
general  chorea,  or  they  remain  more  or  less  limited  to  the 
muscles  of  one-half  of  the  body,  when  the  disease  is  called 
unilateral  chorea  or  hemichorea. 

General  Chorea. — When  once  the  disease  is  fully  established 
the  symptoms  are  quite  characteristic,  and  it  would  be  difficult 
to  find  phrases  more  expressive  of  the  disorderly  muscular  move- 
ments than  "  insanity  of  the  muscles,"  adopted  by  Bellingham, 
and  "  folic  musculaire  "  by  Bouillaud. 

The  features  undergo  every  variety  of  contortion.  The  brow 
is  knit  and  immediately  expanded;  the  eyebrows  are  elevated 
and  the  next  moment  depressed,  or  one  may  be  elevated  while 
the  other  is  lowered  ;  the  eyelids  open  and  close  alternately ;  the 
eyeballs  are  quickly  rotated  in  different  directions ;  the  labial 
commissures  are  suddenly  drawn  outwards,  and  as  quickly 
retracted.  These  opposite  movements  succeed  one  another  with 
such  rapidity  that  the  face  presents  in  quick  succession  the 
most  contradictory  expressions,  such  as  those  of  delight,  vexation, 
and  anger. 

The  tongue  is  thrust  out  of  the  mouth,  and  quickly  retracted 
and  rolled  about  from  side  to  side ;  the  jaws  are  separated  and 


CHOREA.  817 

closed,  it  may  be  with  so  much  violence  that  teeth  are  broken, 
or  the  tongue  and  cheeks  are  severely  bitten ;  lateral  displace- 
ments of  the  lower  jaw  are  frequently  observed,  and  the  head 
is  jerked  suddenly  from  one  side  to  the  other,  while  the  facial 
grimaces  by  which  the  movements  of  the  jaws,  tongue,  and  head 
are  accompanied  add  to  the  comical  appearance  presented  by 
the  patient. 

The  superior  extremities  execute  every  variety  of  movement, 
the  shoulders  are  elevated,  then  lowered,  and  immediately  after- 
wards drawn  backwards  or  forwards  ;  the  arm  and  forearm  are 
moved  at  the  shoulder  and  elbow  joint  in  every  possible 
direction ;  the  hand  is  alternately  pronated  and  supinated, 
flexed  and  extended ;  and  the  fingers  are  at  one  moment 
extended  and  spread  apart  and  at  the  next  flexed.  These 
movements  are  combined  in  such  varied  ways  that  a  gesticu- 
latory  agitation  is  produced  which  defies  description. 

The  muscles  of  the  trunk  are  implicated,  and  their  unequal 
disorderly  contractions  produce  sudden  lateral  and  antero- 
posterior deviations  of  the  vertebral  column,  which  in  certain 
cases  may  be  so  violent  that  the  patient  is  thrown  from  his 
chair  or  out  of  bed.  The  muscles  of  the  lower  extremities  also 
undergo  irregular  contractions,  causing  eversion  and  inversion 
of  the  foot  and  various  contortions  of  the  toes,  as  well  as  move- 
ments at  the  larger  articulations.  Choreic  movements  cease  as 
a  rule  during  sleep  and  under  the  influence  of  chloroform,  but 
in  aggravated  cases  they  may  continue  during  sleep  ;  the  pupils 
are  usually  dilated,  and  their  reaction  to  light  is  diminished. 
The  respiratory  rhythm  becomes  irregular  and  jerky,  and  on 
laryngoscopic  examination  the  vocal  cords  have  been  observed 
to  act  in  an  irregular  and  disorderly  manner  (von  Ziemssen). 

Most  of  the  irregular  movements  just  described  may  occur 
during  repose,  although  they  are  much  exaggerated  when  the 
patient  is  under  observation  or  excited  in  any  way.  When, 
however,  the  patient  endeavours  to  execute  a  voluntary  move- 
ment, the  motor  disorder  becomes,  as  a  rule,  greatly  increased. 
A  distinction  has  been  drawn  by  Dr.  Gowers  between  the 
choreic  movements  that  occur  during  repose,  and  the  motor 
inco-ordination  observed  during  attempts  at  voluntary  move- 
ments which  may  be  called  choreic  ataxia ;  but  whether  this 

AAA 


818  CHOEEA. 

distinction  be  valid  or  not,  it  is  undoubted  that  great  motor 
co-ordination  during  attempts  at  voluntary  movement  may  be 
present  in  cases  in  which  the  choreic  movements  of  repose  are 
slight ;  and,  conversely,  the  voluntary  inco-ordination  may  be 
slight  in  cases  in  which  the  choreic  movements  of  repose  are 
excessive.  In  cases  of  moderate  intensity  delicate  manual 
operations,  such  as  those  required  for  writing,  sewing,  and 
playing  upon  musical  instruments,  alone  become  impossible ; 
while  operations,  like  eating,  requiring  less  complicated  adjust- 
ments for  their  performance,  are  still  effected,  although  in  an 
imperfect  and  round-about  manner,  and  after  frequent  interrup- 
tions from  the  involuntary  contraction  of  antagonistic  muscles. 
In  aggravated  cases  it  becomes  impossible  to  execute  almost 
any  intended  movement.  When  the  patient  endeavours  to 
carry  anything  to  his  mouth,  such  as  a  glass  of  water,  the 
progress  of  his  arm  is  arrested  by  a  series  of  jerks  and 
contradictory  movements  which  may  scatter  the  contents  of 
the  glass  in  every  direction;  the  patient  cannot  button  and 
unbutton  his  clothes ;  the  maintenance  of  the  erect  posture  is 
difficult  or  impossible  ;  and  even  in  the  recumbent  posture  he 
is  not  free  from  the  danger  of  being  thrust  out  of  bed;  his 
clothes  and  linen  become  worn  out  by  constant  rubbing;  and 
the  skin  over  the  prominent  bones  becomes  erythematous  and 
may  ulcerate. 

On  the  patient  being  asked  to  show  the  tongue  he  protrudes 
it  with  a  jerk,  the  mouth  being  opened  to  an  unnecessary 
extent ;  the  tongue  is  immediately  withdrawn,  while  the  mouth 
and  jaws  close  upon  it  with  violence.  When  the  patient  en- 
deavours to  speak  the  convulsive  action  of  the  facial  muscles 
becomes  aggravated;  his  articulation  is  irregular,  jerky,  drawl- 
ing, or  stammering ;  his  voice  is  monotonous ;  and  in  aggra- 
vated cases  his  speech  is  so  disordered  as  to  be  almost  if  not 
entirely  unintelligible.  Spasmodic  contraction  extends  to  the 
muscles  of  mastication  and  deglutition,  and  consequently  these 
functions  are  performed  imperfectly  and  with  difficulty. 

Hemichorea. —  The  spasmodic  phenomena  are  sometimes 
limited  to  the  muscles  of  one-half  the  body,  the  unilateral 
variety  occurring  in  about  one-fifth  of  all  cases.  Some  authors 
state  that  the  left  and  others  that  the  right  is  more  frequently 


CHOREA.  819 

affected,  but  there  does  not  appear  to  be  a  great  difference 
between  their  relative  liability.  Broadbent  asserts  that  the 
muscles  bilaterally  associated  in  their  actions,  and  which  are 
comparatively  spared  in  hemiplegia,  are  affected  to  some  extent 
on  both  sides  in  hemichorea. 

The  other  symptoms  of  hemichorea  are  the  same  as  those  of 
general  chorea,  and  do  not  require  separate  description. 

Although  spasmodic  motor  disturbance  constitutes  the  most 
characteristic  feature  of  chorea,  it  must  not  be  forgotten  that 
a  certain  degree  of  muscular  weakness  is  always  present,  this 
being  easy  of  recognition  in  cases  of  hemichorea.  Indeed, 
towards  the  termination  of  the  affection  or  during  its  course, 
the  choreic  movements  may  be  replaced  by  a  more  or  less 
complete  hemiplegia  or  paraplegia,  and  we  have  already  seen 
that  paralytic  symptoms  may  precede  the  development  of  the 
characteristic  movements. 

The  electric  excitability  of  the  nerves  and  muscles  is  said  to 
be  increased  to  both  currents,  a  fact  more  readily  proved  in 
hemichorea  than  in  the  bilateral  variety  (Rosenthal,  Gowers). 

The  reflex  excitability  is  said  by  some  authors  to  be  increased 
and  by  others  to  be  diminished. 

Sensory  disturbances  are  not  frequently  observed  in  chorea. 
Painful  points  have  been  found  at  times  in  the  course  of  the 
nerve  trunks  of  the  affected  region,  while  tenderness  on  pressure 
over  the  spinous  processes  of  some  of  the  vertebrae  is  occasionally 
met  with.  At  other  times  cutaneous  hypersesthesia  or  hyperal- 
gesia distributed  over  half  or  the  whole  of  the  body  has  been 
observed,  but  anaesthesia  of  like  distribution  is  more  common. 

Vaso-motor  and  secretory  disturbances  are  wanting,  there  are 
no  special  trophic  changes,  and  the  general  health  does  not 
suffer,  except  in  aggravated  and  chronic  cases,  in  which  the  con- 
stant agitation  and  want  of  sleep  induces  a  condition  of  ansemia 
and  general  marasmus. 

Psychical  disturbances  are  invariably  observed  in  chorea. 
The  mental  depression  and  irritability  with  which  the  disease 
begins  usually  increase  during  its  course.  The  patient  is  obsti- 
nate, taciturn,  and  even  violent  towards  parents  and  attendants. 
He  suffers  from  impairment  of  memory,  incapacity  for  thinking, 
and   general  intellectual  weakness.      At  times  there  may  be 


820  CHOEEA. 

hallucinations  of  sight,  especially  at  night,  succeeded  by  a 
maniacal  delirium,  and  according  to  the  observations  of  Marcd, 
half  of  the  cases,  in  which  this  delirium  supervenes,  terminate 
fatally. 

The  pulse  may  be  irregular,  and  the  patient  suffers  from 
palpitation,  while  a  physical  examination  of  the  heart  gene- 
rally reveals  the  presence  of  endocardial  murmurs,  either  arising 
from  disease  of  the  valves  or  of  functional  origin.  Chorea  is 
not  usually  accompanied  by  pyrexia,  but  in  severe  cases,  where 
there  is  violent  muscular  action,  elevation  of  temperature  is  not 
uncommon.  When  it  is  associated  with  acute  rheumatism,  more 
or  less  fever  is  necessarily  present, 

§  900.  Course,  Duration,  and  Results. — Chorea,  as  a  rule, 
runs  a  chronic  course,  lasting  in  the  majority  of  cases  from  six 
to  eight  weeks ;  while  aggravated  cases  may  continue  for  four 
to  five  months.  The  disease  may,  indeed,  last  many  years,  and 
it  is  probable  that  such  cases  are  the  result  of  permanent  ana- 
tomical lesions  in  the  nervous  system. 

The  course  of  the  disease  is  seldom  uniform,  and  relapses 
are  frequent ;  slight  emotional  disturbances  often  aggravate  the 
symptoms  or  induce  a  relapse  during  convalescence. 

Chorea  frequently  recurs  at  varying  intervals.  The  recurrent 
attack  may  be  induced  by  emotional  disturbance,  by  pregnancy, 
or  by  the  presence  of  an  acute  disease.  Most  of  the  relapses 
occur  during  puberty,  but  among  persons  who  were  choreic  at 
or  before  this  period  they  may  appear  at  from  twenty  to  thirty 
years  of  age  or  later. 

The  disease  generally  terminates  in  complete  recovery,  but 
a  nervous  fidgetty  manner,  exhibiting  itself  in  slight  grimaces, 
needless  haste,  and  want  of  precision  in  executing  certain  move- 
ments, often  remains  for  years. 

Termination  in  imperfect  recovery  is  rare.  Sometimes,  how- 
ever, a  few  symptoms  of  chorea  may  persist,  paralysis  may 
develop  in  the  half  of  the  body  which  has  been  most  affected, 
or  permanent  mental  disease,  such  as  mania,  melancholia,  or 
general  paralysis  of  the  insane  become  established.  Death  is 
extremely  rare  in  children  in  uncomplicated  cases,  but  when 
the  disease  is  complicated  with  rheumatism  and  endocarditis  it 


CHOREA.  821 

is  not  unfrequently  fatal.  See  found  a  mortality  of  5'7  per  cent 
in  the  chorea  of  children ;  whilst  the  statistics  of  Wenzel  give 
a  mortality  of  273  per  cent  in  the  chorea  of  pregnant  women. 
The  cause  of  death  in  chorea  is  generally  to  be  assigned  to 
various  complications,  but  occasionally  to  the  intensity  of  the 
disease  itself.  In  the  latter  cases  the  symptoms  are  unusually 
acute  and  violent  from  the  first,  and  attain  excessive  severity 
in  a  few  days  ;  the  choreic  movements  cease  either  suddenly  or 
gradually  and  collapse  sets  in,  along  with  complete  muscular 
relaxation  and  involuntary  evacuations,  and  death  follows 
preceded  by  coma. 

§  901.  Morbid  Anatomy.  —  In  the  old  observations  of 
Cruveilhier,  Romberg,  and  others,  foci  of  softening  were  found 
in  various  parts  of  the  brain,  but  the  absence  of  a  careful 
microscopical  examination  greatly  diminishes  the  value  of  these 
records.  Brown-S^quard  and  Gendron  observed  softening  of 
the  spinal  cord.  Tuckwell  in  1867  found,  at  the  post-mortem 
examination  of  a  patient  dead  of  chorea,  fibrinous  vegetations 
on  the  valves  of  the  heart,  a  branch  of  the  middle  cerebral  and 
another  of  the  posterior  cerebral  artery  occluded  by  emboli,  and 
foci  of  red  softening  in  the  cortex  of  the  brain  corresponding  to 
the  distribution  of  the  occluded  vessels.  It  may  be  noticed  in 
passing  that  Kirkes  had  suggested  in  1850  and  again  in  1863 
that  the  well-known  relation  between  rheumatism  and  chorea 
would  be  found  in  the  endocarditis  caused  by  the  former,  giving 
rise  in  its  turn  to  multiple  embolism  of  the  vessels  of  the  brain. 
Ogle  published  in  1868  an  analysis  of  ninety-six  cases  of  chorea. 
Sixteen  of  these  were  fatal,  and  a  post-mortem  examination 
of  them  was  obtained.  Cardiac  lesions,  consisting  of  fibrinous 
deposits  on  the  valves,  were  found  in  ten  cases  only.  In  six 
congestion  of  the  nervous  centres  was  noted.  In  a  girl  of 
seventeen  who  died  from  maniacal  chorea  during  pregnancy, 
hyperaemia  of  the  surface  and  softening  of  other  parts  of  the 
brain  were  observed.  The  anterior  column  of  the  spinal  cord 
in  the  lower  dorsal  region,  on  a  level  with  the  ninth  dorsal 
nerves,  was  swollen  and  softened.  A  microscopical  examination, 
conducted  by  Lockhart  Clarke,  revealed  softening  of  the  white 
substance  and  extravasations  of  blood,  with  granular  exudation. 


822  CHOREA. 

Steiner,  in  1868,  published  the  results  of  the  post-mortem 
examination  of  three  cases  of  chorea.  He  found  cerebro-spinal 
anaemia,  effusion  of  serum  into  the  spinal  canal,  and  proliferation 
of  the  connective  tissue  in  the  upper  half  of  the  spinal  cord  in 
one  case,  and  in  another  hypersemia  of  the  spinal  cord  and 
brain,  including  their  membranes,  and  an  accumulation  of  fluid 
blood  about  the  roots  of  the  cervical  and  upper  dorsal  nerves. 
Evidences  of  endocarditis  were  found  only  in  one  of  these  cases. 
Fatal  cases  of  the^;  chorea  of  pregnancy,  in  which  no  signs 
of  endocarditis  were  observed,  have  been  recorded  by  Wilks, 
Lawson  Tait,  and  Barnes.  Aitken  found  the  specific  gravity  of 
the  corpora  striata  and  optic  thalami  of  a  person  dead  of  chorea 
much  less  than  that  of  other  parts  of  the  same  brain,  and  of  the 
same  parts  in  healthy  brains.  Numerous  changes  were  found 
in  the  brain  and  spinal  cord  by  Meynert  in  chorea.  The  main 
changes  consisted  of  hyaline  swelling  with  molecular  degenera- 
tion of  the  protoplasm  of  the  cells  of  the  cortex  of  the  brain, 
partial  sclerosis  of  the  cells  of  the  cortex  of  the  island  of  Reil 
and  of  the  basal  ganglia,  and  multiplication  of  the  nuclei  of  the 
nerve  cells.  He  also  found  great  multiplication  of  the  nuclei  of 
the  neuroglia  and  swelling  of  Deiter's  cells  in  the  spinal  cord. 
Elischer  found,  in  a  pregnant  woman  dead  of  chorea,  nuclear 
proliferation,  hyperplasia  of  the  connective  tissue,  and  thickening 
of  the  tunica  adventitia  of  the  small  vessels  in  the  corpus 
striatum,  and  division  of  the  nuclei  of  the  nerve  cells  in  the 
claustrum.  The  spinal  cord  presented  thickening  and  nuclear 
proliferation  in  the  walls  of  the  vessels,  thickening  of  the  epen- 
dyma  of  the  central  canal,  and  nuclear  proliferation  of  the  con- 
nective tissue  around  the  nerve  cells  of  the  grey  matter.  The 
cells  themselves  presented  a  dull  appearance,  were  destitute  of 
nuclei,  and  filled  with  pigment.  The  white  substance  was 
hypersemic,  and  the  lateral  and  posterior  columns  contained 
a  fibrillated  tissue  with  abundant  nuclei.  The  fibres  in  the 
peripheral  nerves  were  diminished  in  number. 

A  valuable  paper  on  "  The  Pathology  of  Chorea"  has  recently 
been  contributed  by  Dr.  Dickinson,  in  which  the  results  of  the 
post-mortem  examination  of  seven  fatal  cases  of  chorea  are 
recorded.  The  changes  described  consist  of  dilatation  of  the 
medium-sized  arteries  and  veins  throughout  the  substance  of 


CHOREA. 


823 


the  brain  and  spinal  cord,  exudations  or  small  hsemorrhages 
indicated  sometimes  by  the  presence  of  blood  crystals,  into  the 
tissues  surrounding  the  distended  vessels,  and  in  chronic  cases 
patches  of  sclerosis  in  the  neighbourhood  of  the  vessels.  These 
changes  were  most  pronounced  in  the  corpora  striata  and  optic 
thalami,  the  anterior  perforated  spaces,  and  at  the  junction  of 
the  posterior  grey  horns  and  central  columns  of  the  spinal  cord, 
especially  in  the  upper  dorsal  and  cervical  regions.  In  one  case 
the  central  canal  of  the  dorsal  region  of  the  spinal  canal  was 
greatly  distended  by  bloody  serum.  "Speaking  generally," 
says  Dr.  Dickinson,  "  the  chosen  seats  of  the  choreic  changes 
are  the  parts  of  the  brain  which  lie  between  the  beginning  of 
the  middle  cerebral  arteries  and  the  corpora  striata — the  partes 
perforatse ;  and  in  the  cord  the  central  portion  of  each  lateral 
mass  of  grey  matter  comprising  the  root  of  each  posterior  horn." 
It  will  be  evident  how  these  observations  of  Dr.  Dickinson  bear 
out  the  theory  advanced  in  these  pages  as  to  the  great  patho- 
logical importance  of  the  parts  of  the  nervous  system  which  I 
have  termed  accessory, 

A  microscopical  examination  of  the  nervous  system  in  a  case 

Fig.  283. 


Fig.  283  (Young).    Section  of  the  Cervical  Region  of  the  Spinal  Cord  from  a  case  of 
Chorea.  — cc,  Central  canal ;  A.  and  P,  Anterior  and  Posterior  horns  respectively. 


824  CHOREA. 

of  fatal  chorea,  which  I  had  the  opportunity  of  making,  enables 
me  to  confirm  to  a  large  extent  the  statements  of  Dr.  Dickinson. 
In  the  cases  he  describes  periarterial  erosions  and  haemorrhages 
occurred  around  the  central  artery  and  its  primary  branches, 
while  in  my  case  the  most  pronounced  changes  were  found  in 
the  anterior  and  antero -lateral  arteries.  All  the  vessels  of  the 
cord  were  more  or  less  distended  with  red  blood  corpuscles,  but 
in  some  sections  a  fibrinous  plug  was  observed  in  the  anterior 
or  antero-lateral  arteries,  the  vessel  being  distended  by  it  {Fig. 
283).  Spots  of  necrotic  softening  were  observed  in  the  corpora 
striata.  A  section  of  the  spinal  cord  from  a  case  of  chorea  was 
exhibited  by  Dr.  Bury  at  the  Manchester  Microscopical  Society, 
in  which  the  periarterial  exudations  and  haemorrhages  round  the 
branches  of  the  central  artery  were  distinctly  shown  {Fig.  284), 

Fig.  284. 


Fig.  284  (Bury).  Section  of  the  Anterior  Grey  Horn  of  the  Cervical  Enlargement  of 
the  Spinal  Cord  from  a  case  of  Chorea  that  died  on  the  fourth  day  of  Scarlet 
Fever. — cc,  Central  canal ;  ac,  Anterior  commissure  ;  A,  Anterior  horn. 


and  corresponded  accurately  to  the  description  and  drawings  of 
Dr.  Dickinson.  But  although  no  decided  changes  were  observed 
in  the  tissues  near  the  central  artery  of  the  spinal  cord  in  the 
case  examined  by  me,  I  was  struck  with  the  alterations  presented 
by  the  accessory  cells  of  the  anterior  grey  horns  in  comparison 
with  the  fundamental  cells.     The  accessory  cells  could  not  be 


CHOREA.  825 

seen  with  a  low  power,  and  are  therefore  not  represented  in 
the  diagram  ;  but  with  a  higher  power  they  appeared  shrivelled, 
their  protoplasm  was  granular,  the  nuclei  were  obscure,  and 
many  of  the  processes  were  indistinct  or  absent.  The  larger 
fundamental  cells  did  not  appear  much  altered.  Of  twenty- 
two  fatal  cases  of  chorea  collected  by  Dr.  Dickinson  the  heart 
was  found  healthy  in  five  only,  and  of  these  one  only  was  a 
child.  As  Dr.  Dickinson  remarks,  endocarditis  appears  to  be  an 
almost  invariable  accompaniment  of  fatal  chorea  in  children, 
while  beading  of  the  mitral  valve  with  lymph  is  probably 
present  in  every  instance  of  cardiac  complication.  In  the  case 
observed  by  me  the  free  edges  of  the  mitral  valve  were  fringed 
by  a  row  of  fibrinous  beads. 

§  902.  Morhid  Physiology.  —  In  1868,  Broadbent  and 
Hughlings-Jackson  almost  simultaneously  advanced  the  hypo- 
thesis that  the  corpus  striatum  and  optic  thalamus  are  the 
main  centres  in  which  the  lesions  in  chorea  are  localised. 
Hughlings-Jackson  surmised  that  the  convolutions  of  the  cortex 
situated  near  the  corpus  striatum  were  also  involved  in  the 
disease.  The  observations  of  Meynert,  Dickinson,  and  others 
confirmed  by  the  case  examined  by  myself,  prove  that  the 
lesions  are  widely  distributed  throughout  the  brain  and  spinal 
cord. 

An  endeavour  has  been  made  to  determine  the  localisation  of  the 
lesion  in  chorea  by  experimental  investigation.  Chauveau  divided  the 
spinal  cord  close  to  the  skull  in  a  dog  suffering  from  general  chorea,  and 
found  that  the  choreic  movements  continued  unabated  until  the  death  of 
the  animal  several  hours  after  the  operation.  The  convulsive  movements 
of  the  tail  and  posterior  extremities  ceased  immediately  on  the  spinal  cord 
being  divided  in  the  dorsal  region.  From  the  results  of  these  experiments, 
Chauveau  concluded  that  the  spinal  cord  is  the  seat  of  the  lesion.  Similar 
experiments  were  conducted  by  Longet,  Bert,  and  Carville,  and  the  same 
conclusion  arrived  at. 

Legros  and  Onimus  found  that  irritation  of  the  posterior  columns  of 
the  exposed  cord  with  the  scalpel  increased  the  twitchings.  The  choreic 
movements  ceased  on  the  cord  being  exposed  to  a  current  of  cold  air, 
and  reappeared  on  its  being  subsequently  moistened  with  warm  water. 
Section  of  the  posterior  roots  did  not  exert  any  influence  on  the  choreic 
movements.  Partial  removal  of  the  posterior  cornua  and  columns 
weakened,  and  complete  excision  of  them  abolished  the  movements.     An 


826  CHOEEA. 

ascending  galvanic  current  through  the  cord  increased  the  intensity  and 
frequency  of  the  contractions ;  while  a  descending  current  weakened 
them  considerably.  The  authors  conclude  from  these  experiments  that 
the  morbid  process  in  chorea  implicates  the  nerve  cells  of  the  posterior 
grey  cornua  of  the  spinal  cord,  or  the  nerve  fibres  which  unite  them  with 
the  cells  of  the  anterior  cornua.  Rosenthal  injected  fine  flower  seeds  into 
rhe  left  carotid  artery  of  a  dog  suffering  from  choreic  movements  of  the 
right  fore-leg.  All  voluntary  movements  were  instantly  arrested,  but 
choreic  movements  became  much  stronger  in  the  affected  extremity,  and 
involved  the  eyelids  and  tail,  lasting  until  the  animal  died  two  days 
subsequently.  The  auto]3sy  revealed  encephalitis  of  the  left  anterior  lobe, 
softening  of  the  left  corpus  striatum,  and  embohsm  of  the  left  Sylvian 
artery.  A  microscopic  examination  conducted  by  Dr.  Scheiber  showed 
spots  of  proliferated  connective  tissue  in  many  parts  of  the  brain  sub- 
stance. Canine  chorea  is  by  no  means  the  same  disease  as  that  of  the 
same  name  in  nlan,  and  it  would  be  hazardous  to  attach  much  importance 
to  any  of  these  experiments. 

The  nature  of  the  lesion  in  chorea  has  been  a  subject  of  as 
much  controversy  as  its  localisation.  The  relation  between 
rheumatism  and  chorea  had  been  known  for  a  long  time,  and 
Bright  went  so  far  as  to  assert  that  rheumatic  pericarditis  was 
the  most  frequent  cause  of  chorea.  In  1850,  and  again  in  1863, 
Kirkes  suggested  that  endocarditis  was  the  causal  link  between 
rheumatism  and  chorea.  According  to  this  opinion,  chorea 
was  caused  by  embolic  particles  washed  off  from  the  inflamed 
endocardium  and  arrested  in  the  vessels  of  the  brain  and  spinal 
cord.  Hughlings-Jackson  adopted  this  view,  and  in  1868  he 
advanced  the  opinion  that  chorea  was  caused  by  multiple 
embolism  of  the  nutritive  arteries  of  the  basal  ganglia  and 
convolutions  of  the  cortex  of  the  brain  situated  near  to  the 
corpus  striatum.  It  cannot  be  doubted  that  embolism  of  the 
vessels  of  the  nervous  centres  does  occur  at  times  in  chorea, 
inasmuch  as  some  of  the  vessels  of  the  brain  have  been  found 
actually  occluded  by  an  embolus  in  fatal  cases,  while  the  con- 
dition liable  to  occasion  embolism  is  present  in  a  very  large 
proportion  of  fatal  cases.  On  the  other  hand,  in  some  fatal 
cases  there  has  been  an  entire  absence  of  cardiac  complication. 
Again,  of  the  large  majority  of  cases  which  recover,  although  a 
cardiac  complication  is  frequently  present,  yet  this  is  by  no  means 
invariable.  It  may,  therefore,  be  concluded  that  although  chorea 
may  be  caused  by  multiple  embolism  of  the  vessels  of  the  nervous 


CHOREA.  827 

system,  yet  the  affection  may  occur  in  the  absence  of  embolism, 
and  it  is  not,  therefore,  the  essential  condition  upon  which  the 
disease  depends.  Similar  reasoning  applies  to  the  opinion  of 
the  humoral  pathologists,  who  believe  that  chorea  is  caused 
by  the  rheumatic  diathesis,  or  by  the  poison  of  rheumatism 
circulating  in  the  blood,  producing  irritation  of  the  tissues 
of  the  nervous  system.  Chorea  may  occur  in  the  absence 
of  a  history  of  active  rheumatism.  "  We  see  in  chorea," 
says  Dr.  Dickinson,  "  a  widely  distributed  hypersemia  of  the 
nervous  centres,  not  due  to  any  mechanical  mischance,  but 
produced  mainly  by  causes  of  two  kinds — one  a  morbid,  pro- 
bably a  humoral,  influence,  which  may  affect  the  nervous  centres 
as  it  affects  other  organs  and  tissues  ;  the  other,  irritation  in 
some  mode,  usually  mental,  but  sometimes  what  is  called  reflex, 
which  especially  belongs  to  and  disturbs  the  nervous  system, 
and  effects  persons  differently,  according  to  the  inherent 
mobility  of  their  nature." 

To  turn  to  the  first  factor,  it  must  be  remembered  that  dis- 
tension of  the  blood  vessels  of  the  nervous  system  after  death 
by  no  means  proves  the  existence  of  an  active  hypersemia  during 
life.  The  conditions  usually  present,  such  as  cardiac  disease, 
are  such  as  to  cause  anaemia  of  the  nervous  system,  and  the 
phenomena  of  chorea  are  best  explained  on  the  supposition 
that  the  excess  of  irritability  of  the  nervous  centres  is  caused 
by  defective  nutrition  of  their  tissues. 

With  regard  to  the  second  factor,  the  profound  mental  im- 
pression causing  chorea  is  usually  fright,  one  of  the  depressing 
passions,  which  is  certainly  more  calculated  to  exhaust  the  irri- 
tability of  the  nervous  system  than  to  maintain  it  in  a  state  of 
continuous  activity  through  irritation.  Reflex  irritation  is  also 
more  likely  to  act  by  causing  anaemia  rather  than  hypersemia. 

The  third  co-operating  factor — inherent  instability  of  the 
nervous  centres — is  a  very  important  one.  It  is  probable  that 
the  children  in  some  families  inherit  an  unstable  nervous  sys- 
tem, which  renders  them  liable  to  be  directly  affected  by  chorea, 
but  this  has  not  been  definitely  proved  as  yet.  It  is  not  doubted, 
however,  that  an  inherent  tendency  to  develop  the  disease 
at  a  certain  age  exists.  As  Dr.  Dickinson  remarks,  "  Every 
period  of  life  has  its  own  regions  of  nervous  susceptibility :  in 


828  CHOREA. 

childhood  the  motor  ;  in  adolescence  the  emotional ;  in  advan- 
cing years  the  mental,  and  coevally,  or  nearly  so,  that  part  of 
the  nervous  mechanism  which  instigates  glycosuria.  Much  the 
same  mental  impression  may  make  a  child  choreic,  a  girl  hyste- 
rical, or  a  man  diabetic."  In  chorea  the  sensory  and  psychical 
functions  of  the  nervous  centres  are  disturbed,  but  the  great 
weight  of  the  disease  falls  upon  the  motor  functions,  and  of  the 
latter  the  last-developed  co-ordinations  of  the  muscles  of  the 
hand  and  of  the  face  and  tongue  are  implicated  in  a  special 
degree. 

We  have  already  seen  that  the  most  pronounced  lesions  in 
chorea  are  found  in  what  I  have  called  the  embryonic  portions 
of  the  motor  area  of  the  cortex  and  corpus  striatum,  and  of  the 
motor  grey  matter  of  the  cord,  and  consequently  whether  chorea 
be  viewed  functionally  or  structurally,  it  appears  to  be  a  widely 
distributed  disease  of  the  nervous  centres,  in  which  the  cerebro- 
spinal motor  functions  and  mechanisms  are  specially  affected, 
the  accessory  functions  and  structures  being  affected  at  an 
earlier  period  and  more  profoundly  than  the  fundamental 
functions  and  structures.  I  came  to  this  conclusion  after 
making  a  microscopical  examination  of  the  nervous  system  in 
the  case  above  referred  to,  and  was  not  aware  at  the  time  that 
Hughlings- Jackson,  approaching  the  subject  from  the  clinical 
standpoint,  had  come  to  practically  the  same  conclusion  upwards 
of  ten  years  before.  "  Since  the  disorder  in  chorea,"  he  says,  "  is 
of  movements  which  are  acquired,  and  which  are  probably  only 
fully  learned  by  a  long  apprenticeship,  I  used  to  suppose  that 
the  nervous  arrangements  for  these  movements  were  but  par- 
tially developed  in  children,  and  that  the  motor  processes 
involved,  and  their  arterial  integration,  would  be,  so  to  speak, 
caught  in  a  stage  of  incomplete  development — in  short,  that 
their  centres  were  diseased  when  ^,a^/-educated."  In  the  same 
paper  he  attributes  the  symptoms  to  "  under-nutrition"  of  the 
tissues  affected. 

§  903.  Diagnosis. — The  diagnosis  of  chorea  can  hardly 
present  any  difficulty.  Paralysis  agitans  occurs  in  the  later 
years  of  life,  and  the  attitude  of  the  patient  and  his  mode  of 
locomotion  are  so  characteristic  that  this  disease  is  no  more 


CHOEEA.  829 

likely  to  be  mistaken  for  chorea  than  is  the  tremor  associated 
with  old  age,  and  with  chronic  poisoning  by  alcohol,  lead,  or 
mercury.  The  spasmodic  movements  occurring  in  groups  of 
muscles  supplied  by  certain  nerves,  such  as  convulsive  tic,  and 
those  occurring  in  definite  groups  of  muscles  engaged  in  per- 
forming certain  actions,  as  in  the  case  of  writer's  cramp,  are 
also  separated  from  the  movements  of  chorea  by  broad  lines  of 
demarcation. 

§  904.  Prognosis. — The  prognosis  of  chorea  is,  as  a  rule, 
favourable.  It  becomes  grave,  however,  when  the  movements 
are  so  violent  as  to  exhaust  the  patient,  cause  sleeplessness,  and 
prevent  sufficient  food  being  taken,  or  when  there  is  delirium. 
The  chorea  of  pregnancy  is  much  more  fatal  than  that  which 
occurs  about  and  before  puberty. 

§  905.  Treatment.—  In  the  treatment  of  chorea  the  diet 
should  be  carefully  regulated;  and  any  source  of  reflex  irritation, 
such  as  intestinal  worms,  should  be  removed.  If  anaemia  be 
present,  iron  may  be  given,  either  alone  or  along  with  cod  liver 
oil ;  while  if  rheumatism  complicate  the  case,  salicylate  of  soda 
must  be  administered.  The  use  of  the  hot  vapour  bath  has 
been  much  praised  in  the  treatment  of  chorea,  and  it  is  worth  a 
trial  in  cases  in  which  a  rheumatic  diathesis  can  be  traced,  even 
if  there  be  no  active  rheumatism  at  the  time  of  the  attack. 
The  child  should  be  immediately  removed  from  school,  all  in- 
tellectual work  suspended,  and  even  bodily  exertion  avoided  in 
the  early  stage  of  the  disease. 

The  medicines  which  appear  to  do  most  good  are  the  nervine 
tonics,  and  of  these  arsenic  is  probably  the  best.  Ziemssen 
recommends  a  dose  of  from  five  to  eight  drops  of  Fowler's 
solution  for  children,  and  eight  to  twelve  drops  for  adults. 
Most  practitioners  will  be  inclined  to  begin  with  a  smaller 
dose  and  gradually  increase  it.  Iron  may  be  combined  with 
arsenic  if  the  patient  be  anaemic  and  the  stomach  bears  it  well. 
If  the  arsenic  has  not  produced  a  decided  improvement  in  the 
symptoms  within  a  period  of  a  week  or  ten  days,  zinc  may  be 
substituted,  the  sulphate  being  the  most  convenient  preparation 
and  as  successful  as  any  other.     A  dose  of  two  or  three  grains 


830  Meniere's  disease. 

may  be  given  at  first  three  times  a  day,  but  this  dose  must  be 
gradually  increased  daily ;  if  nausea  or  vomiting  be  produced, 
the  dose  should  be  slightly  diminished  for  a  few  days  until 
tolerance  is  established.  After  this  it  should  be  again  gradually 
increased  until  the  symptoms  begin  to  improve,  and  then  con- 
tinued without  alteration  until  improvement  ceases  or  the 
disease  subsides.  The  tolerance  for  the  drug  becomes  so  great 
after  a  short  time  that  15  to  20  grains  may  be  given  three 
times  a  day  to  a  patient  15  years  of  age,  without  nausea  or  any 
other  ill  effects  being  produced.  I  have  made  a  fair  trial  of 
the  valerianate  and  the  bromide  of  zinc,  but  have  not  found 
these  salts  to  be  in  any  way  superior  to  the  sulphate.  Bromide 
of  potassium  does  not  appear  to  me  to  exert  any  favourable 
influence  on  the  progress  of  the  disease,  but  it  may  be  usefully 
administered  with  or  without  chloral  when  psychical  distur- 
bance and  sleeplessness  are  prominent  symptoms. 


(II.)   MENIERE'S   DISEASE. 

(Auditory  Vertigo.) 

§  906.  Definition. — Meniere's  disease  is  characterised  by 
attacks  of  vertigo,  associated  with  noises  in  one  or  both  ears, 
and  partial  deafness. 

§  907.  Etiology. — All  the  causes  which  produce  disease  of 
the  peripheral  organ  of  hearing  may  occasion  auditory  vertigo, 
and  they  need  not,  therefore,  be  enumerated  here. 

§  908.  Symptoms. — The  characteristic  symptoms  of  Meniere's 
disease  are  sometimes  preceded  by  partial  deafness,  earache, 
and  other  indications  of  a  local  lesion  of  the  peripheral  organ 
of  hearing.  In  other  cases  the  patient  is  suddenly  attacked 
with  noises  in  one  ear,  and  a  feeling  of  giddiness,  attended  by 
faintness,  nausea,  and  vomiting.  The  attack  passes  off  in  a 
few  seconds  or  minutes,  but  recurs  after  a  variable  period,  the 
paroxysms  becoming  more  aggravated  and  more  frequently 
repeated  as  the  disease  advances. 

The  noise  is  sometimes  heard  in  both  ears,  but  it  is  probably 
always  more  pronounced  on   one  side  than  the  other.     It  is 


Meniere's  disease,  831 

sometimes  compared  to  the  loud  whistling  of  a  steam  engine, 
^t  other  times  to  a  succession  of  explosions,  and  it  is  often 
described  as  a  continuous  humming  or  buzzing.  The  noises  in 
the  ear  cease  with  the  attack  of  vertigo,  in  recent  or  slight 
cases ;  but  in  aggravated  forms  of  the  affection  they  continue 
to  distress  the  patient  during  the  intervals. 

The  attack  of  vertigo  varies  in  duration  and  intensity.  In 
slight  cases  it  consists  of  a  momentary  feeling  of  swim- 
ming in  the  head,  in  severe  cases  each  paroxysm  may  extend 
over  a  period  of  ten  or  more  minutes,  while  in  still  more  aggra- 
vated cases  the  feeling  of  uncertainty  and  giddiness  is  never 
absent  during  waking  hours,  and  every  effort  on  the  part 
of  the  patient  to  assume  the  erect  posture  determines  the 
vertigo  along  with  nausea  and  vomiting.  During  the  paroxysm 
the  patient  feels  as  if  he  were  falling  forwards,  backwards, 
or  laterally,  or  were  rotating  round  a  vertical  or  hori- 
zontal axis;  he  staggers  and  clutches  at  surrounding  objects 
for  support,  or  actually  falls  in  a  direction  corresponding 
with  his  sensations.  The  patient  during  the  paroxysm  feels 
faint;  the  skin  becomes  pallid,  cold,  and  covered  with  sweat; 
the  pulse  is  feeble  and  flickering;  and  there  is  an  intense  feeling 
of  nausea,  which  often  terminates  in  vomiting,  when  the 
attack  usually  comes  to  an  end.  Actual  syncope  may  occa- 
sionally occur,  and  there  may  be  transitory  loss  of  conscious- 
ness, but  this  is  exceptional.  The  patient,  however,  during  the 
paroxysm  suffers  from  confusion  of  ideas,  and  in  the  worst 
cases  any  unusual  intellectual  effort  may  determine  an  attack 
of  vertigo. 

Oscillatory  movements  of  the  eyeballs  have  been  observed  by 
Schwabach  and  Hughlings- Jackson  during  the  attack.  In  the 
case  observed  by  Schwabach,  as  quoted  by  Hughlings-Jackson, 
the  eyes  were  turned  towards  the  affected  side  and  slightly 
downwards ;  while  in  the  case  observed  by  Hughlings-Jackson 
himself,  '•  each  eye  was  partially  and  very  slightly  rotated  to 
the  right  in  frequent  jerks  from  left  to  right,"  the  left  ear  being 
the  diseased  one.  During  the  attacks  there  was  an  apparent 
displacement  of  objects  with  reference  to  the  patient;  and  in 
the  case  described  by  Hughlings-Jackson,  objects  were  said 
to  revolve,  contrary  to  what  might  have  been  expected,  from 


832      •  Meniere's  disease. 

left  to  right,  or  in  the  same  direction  as  the  rotation  of  the 
eyes.  An  instructive  case  of  this  disease  is  recorded  by  Mr. 
Lewis  Mackenzie  and  quoted  by  Hughlings- Jackson,  in  which 
the  patient — a  medical  man — was  much  distressed  by  con- 
tinuous noises  in  the  right  ear,  following  the  discharge  of  a 
heavily-loaded  gun  near  it,  and,  along  with  the  other  more 
usual  symptoms  of  auditory  vertigo,  there  was  manifested  a 
constant  tendency  to  walk  to  the  left. 

§  909.  Course,Duration,  and  Terminations. — The  paroxysms 
of  vertigo  come  on  at  first  at  irregular  intervals ;  .they  increase 
gradually  in  frequency  and  intensity,  and  in  aggravated  cases 
the  patient  suffers  continuously  from  some  degree  of  vertigo, 
while  he  is  liable  to  paroxysmal  exacerbations  of  great  severity. 
The  noises  in  the  ears  may  cease  at  first  during  the  intervals, 
but  after  a  time  become  constant.  The  sense  of  hearing 
becomes  gradually  diminished,  and  ultimately  complete  deaf- 
ness of  the  affected  ear  is  established,  when,  fortunately,  the 
paroxysms  of  vertigo  and  all  the  distressing  symptoms  of  the 
disease  cease. 

§  910.  Morbid  Anatomy  and  Physiology. — Several  post- 
mortem examinations  have  revealed  the  presence  of  inflam- 
matory exudation  in  the  semicircular  canals.  The  symptoms 
under  consideration  are,  however,  often  associated  with  disease 
of  the  middle  or  external  ear,  but  in  such  cases  some  indirect 
influence  is  probably  exerted  on  the  labyrinth. 

§  911.  Diagnosis  and  Prognosis. — Auditory  vertigo  is  liable 
to  be  mistaken  for  the  vertigo  associated  with  gastric  disease  or 
sexual  excess,  the  diagnosis  being  rendered  more  difficult  by 
the  fact  that  a  considerable  degree  of  deafness  and  noises  in 
the  ears  may  be  present  in  the  latter.  In  auditory  vertigo  the 
noises  are  unilateral,  the  feeling  of  vertigo  is  very  intense,  and 
is  accompanied  by  a  sensation  as  if  the  body  had  undergone 
actual  displacement ;  these  symptoms  never  occur  to  the  same 
degree  in  the  vertigo  of  dyspepsia  or  sexual  excess.  Paroxysms 
of  auditory  vertigo  may  be  mistaken  for  epileptic  attacks, 
and  can  only  be  distinguished  by  a  careful  examination  of  the 


Meniere's  disease.  833 

symptoms.  The  prognosis  is  grave  as  far  as  ultimate  recovery  is 
concerned,  but  the  symptoms  disappear  when  complete  deafness 
is  established. 

§  912.  Treatment. — If  the  symptoms  depend  upon  disease 
of  the  external  or  middle  ear,  the  patient  should  be  placed 
under  the  care  of  the  specialist,  and  when  the  local  disease 
is  not  accessible  to  treatment,  relief  may  be  obtained  by  rest  in 
the  recumbent  posture.  The  administration  of  four  or  five 
grains  of  quinine  three  times  a  day  appears  to  have  produced 
great  amelioration  of  the  symptoms  in  several  cases  (Charcot, 
Hughlings- Jackson). 


BBB 


834 


CHAPTER    III. 


EPIDEMIC    CEEEBRO-SPINAL    MENINGITIS,    TETANUS,  AND 
HYDROPHOBIA. 


(I.)    EPIDEMIC   CEREBRO-SPINAL  MENINGITIS. 

§  913.  Definition. — Epidemic  cerebro-spinal  meningitis  is 
an  acute  epidemic  fever,  characteristic  symptoms  of  which  are 
caused  by  a  purulent  inflammation  of  the  spinal  and  cerebral 
pia  mater. 

§  914.  History.  —  This  disease  probably  prevailed  in  ancient  times, 
but  we  have  no  reliable  accounts  of  it  before  the  present  centm'y. 
The  first  epidemic  prevailed  in  Geneva,  in  the  early  months  of  1805. 
Then  followed  epidemics  in  Grenoble  (1814),  Vesoul  (1822),  and  Dorsten 
on  the  Lippe  (1833).  The  disease  appeared  in  Southern  France  in  1837, 
and  remained  confined  for  many  years  to  the  barracks.  About  the  time 
that  it  attained  its  highest  development  in  France  the  epidemic  extended 
to  Italy,  and  prevailed  there  from  1839  to  the  spring  of  1845. 

In  1844  a  transient  epidemic  occurred  in  Gibraltar,  the  following  year 
in  Denmark,  and  in  1846  it  appeared  in  the  workhouses  of  Ireland,  while 
a  few  cases  were  observed  in  Liverpool.  The  disease  appeared  in  Sweden 
in  1854  and  reappeared  in  1861 ;  there  was  an  epidemic  in  Norway  in 
1859—1860. 

The  disease  may  be  traced  back  in  the  United  States  to  the  beginning 
of  the  century,  but  it  made  active  progress  during  the  year  1842,  and 
prevailed  with  great  intensity  during  the  civil  war.  In  the  last  few  years 
it  has  appeared  in  Canada,  and  it  has  never  entirely  disappeared  from 
the  United  States,  declaring  itself  either  in  sporadic  cases  or  in  small 
epidemics. 

Sporadic  cases  have  been  observed  in  the  United  Kingdom ;  but  the 
most  fatal  epidemic  began  in  Ireland  in  March,  1866,  and  attained  its 
chief  development  in  the  following  winter.  Its  effects  were  almost 
entirely  confined  to  Ireland,  the  worst  cases  occurring  in  Dublin.  In 
1876  a  shght  epidemic  occinred  in  Birmingham. 


EPIDEMIC   CEKEBRO-SPINAL  MENINGITIS.  835 

§  915.  Etiology. 

Predisposing  Causes. — When  the  disease  was  first  noticed  in 
Southern  France  in  1837,  and  in  the  subsequent  outbreaks  up 
to  1849,  it  was  almost  entirely  confined  to  soldiers.  Raw 
recruits  were  specially  liable  to  be  affected,  and  this  liability 
was  probably  largely  due  to  great  physical  exertion  and  an 
overcrowded  condition  of  the  garrisons.  In  subsequent  out- 
breaks, however,  in  France  and  elsewhere  no  special  liability  to 
the  disease  has  been  manifested  amongst  those  engaged  in 
particular  employments. 

In  the  earlier  epidemics  males  were  almost  exclusively 
attacked ;  and,  although  subsequent  observation  has  not  con- 
firmed the  idea  that  the  disease  is  peculiar  to  men,  it  is  much 
more  common  in  them.  Age  does  not  appear  to  have  any 
particular  influence  in  the  production  of  the  disease.  In  some 
epidemics  children,  in  others  young  people,  and  still  in  others 
adults  of  from  thirty  to  thirty-five  have  been  attacked  in 
greatest  proportion. 

The  disease  is  especially  prevalent  in  the  cold  months  of  the 
year,  and,  notwithstanding  some  apparent  exceptions,  it  is 
undoubtedly  more  prevalent  amongst  the  poor  and  ill-fed  than 
the  afifluent  classes.  In  a  large  number  of  epidemics  it  almost 
exclusively  prevailed  amongst  the  inmates  of  prisons,  work- 
houses, and  overcrowded  garrisons. 

§  916.  Symptoms. — Epidemic  cerebro-spinal  meningitis  may 
be  divided  into  four  varieties  :  (1),  the  simple  ;  (2)  the  fulmi- 
nant;  (3),  the  purpuric  ;  and  (4),  the  abortive  forms. 

(1)  Simple  Epidemic  Cerehro- Spinal  Meningitis. — Pre- 
monitory symptoms  are  sometimes  observed,  consisting  of  loss 
of  appetite,  lassitude,  and  neuralgic  pains  in  the  back  and 
abdomen.  As  a  rule,  however,  the  patient  is  suddenly  seized, 
while  following  his  ordinary  occupations,  or  at  play,  with  shiver- 
ing, vomiting,  and  headache  (Burdon-Sanderson).  Profuse  and 
uncontrollable  vomiting  is  almost  a  constant  symptom,  the 
ejected  matters  consisting  at  first  of  half-digested  food  and 
subsequently  of  mucus  stained  with  bile.  Delirium  now  super- 
venes, sometimes  so  violent  in  character  that  it  is  necessary  to 


836  EPIDEMIC   CEREBRO-SPINAL  MENINGITIS. 

place  the  patient  under  restraint,  but  he  is  usually  apathetic 
and  drowsy,  and  only  talks  of  imaginary  objects  when  roused. 

The  patient  soon  complains  of  an  agonising  pain  in  the 
occiput  and  nape  of  the  neck,  which  may  extend  along  the 
spine  and  is  aggravated  by  movement  and  pressure.  The 
abdominal  muscles,  as  well  as  those  of  the  back  and  loins, 
are  acutely  painful,  and  any  movement  rendering  them  tense 
occasions  great  pain.  The  skin  becomes  extremely  sensitive, 
and  severe  pain  is  felt  in  the  limbs,  but  it  is  difficult  to  deter- 
mine how  much  is  due  to  cutaneous  or  muscular  hyperaesthesia. 
The  head  is  retracted,  partly  from  spasm  of  the  muscles  of  the 
nape  of  the  neck,  but  mainly  as  an  instinctive  means  of  relaxing 
the  muscles  in  order  to  relieve  pain.  In  no  case  coming  under 
the  observation  of  Dr.  Burdon-Sanderson  were  the  contractions 
of  the  muscles  of  the  back  of  the  neck  of  such  a  character  as  to 
be  correctly  called  tetanic.  "  The  patients,"  says  Dr.  Sanderson, 
"  invariably  lay  on  their  sides,  with  their  knees  drawn  up  so  as 
to  relieve  the  abdominal  muscles,  and  with  the  face  looking 
towards  the  head  of  the  bed,  and  excessive  pain  was  produced 
whenever  the  body  was  moved  in  such  a  way  as  to  extend  the 
painful  muscles,  and  more  particularly  when  the  patient  was 
lifted  in  bed."  The  period  of  invasion  lasts  from  one  to  three 
days,  and  is  then  followed  by  the  stage  of  depression. 

The  mental  confusion  and  low-muttering  delirium,  which  is 
present  in  the  stage  of  invasion,  now  gives  place  to  stupor,  which 
in  fatal  cases  ends  in  profound  coma.  The  patient  lies  in  a 
somnolent  condition,  although  often  able  to  answer  questions 
when  roused.  The  symptoms  are  liable  to  undergo  considerable 
fluctuations ;  at  times  the  sopor  predominates,  at  other  times 
there  are  restlessness  and  nocturnal  delirium,  and  the  patient 
continues  to  complain  of  pains  in  the  back  of  the  neck  and  in 
the  loins.  Tremors  are  observed  in  the  extremities,  the  pulse 
is  slow,  the  face  is  livid,  the  pupils  dilated  or  contracted, 
and  strabismus,  amblyopia,  or  deafness  is  not  unusually  pre- 
sent. In  several  children  seen  by  Dr.  Burdon-Sanderson  the 
symptoms,  shortly  after  the  cessation  of  the  initial  period,  were 
very  similar  to  those  of  tubercular  meningitis.  An  exanthe- 
matous  eruption  appears  about  the  mouth,  either  like  that  of 
measles  or  scarlet  fever,  and  occasionally  herpetic  in  character; 


EPIDEMIC  CEREBRO-SPINAL  MENINGITIS.  837 

it  spreads  upwards  over  the  eyelids  and  ears,  and  downwards 
over  the  chin  and  neck. 

The  degree  of  pyrexia  varies  greatly  in  different  cases,  but 
the  temperature  usually  ranges  from  100°  F.  to  103°  F.,  or  in 
fatal  cases  to  105°  F,  or  higher.  The  tongue  may  be  clean,  the 
bowels  are  usually  constipated,  and  the  abdomen  is  retracted. 
The  urine  is  frequently  albuminous,  destitute  of  chlorides,  and 
contains  a  relatively  large  proportion  of  urates,  while  polyuria 
and  saccharine  urine  have  occasionally  been  observed. 

In  unfavourable  cases  the  coma  increases  and  becomes  asso- 
ciated with  more  pronounced  paralytic  symptoms,  such  as  ptosis, 
strabismus,  and  paresis  of  the  extremities.  The  pulse  is  feeble, 
and  irregular  or  intermittent ;  the  respiration  is  embarrassed,  a 
slow  and  laboured  inspiration  being  followed  by  a  quick  expira- 
tion and  a  long  pause  (Burdon-Sanderson);  the  skin  is  cyanotic, 
and  covered  with  a  cold  sweat  as  in  the  algide  stage  of  cholera; 
and  the  patient  soon  sinks. 

The  disease  frequently  terminates  favourably,  the  amend- 
ment being  indicated  by  a  gradual  subsidence  of  the  nervous 
phenomena,  restoration  of  the  mental  faculties,  and  a  steady 
fall  in  temperature.  If  the  progress  towards  recovery  be  un- 
interrupted, health  is  re-established  in  from  three  to  four  weeks. 
Convalescence  is,  however,  often  delayed  for  a  long  time  by 
relapses,  and  in  such  cases  recovery  is  often  incomplete, 

(2)  Fulminant  Epidemic  Cerebro-Spinal  Meningitis. — In 
this  variety  the  patient  falls  without  any  premonitory  symptom 
into  a  state  of  collapse,  drowsiness  rapidly  supervenes,  and  is 
quickly  followed  by  coma.  Purpuric  spots  appear  over  the 
surface  of  the  body  generally ;  these  soon  change  from  a  purple 
to  a  black  colour,  and  are  often  confluent  so  as  to  form  irregular 
patches.  Death  may  ensue  in  less  than  five  hours,  or  life  may 
be  prolonged  for  two  or  three  days ;  recovery  is  not  unknown 
even  in  this  form. 

(3)  Purpuric  Epidemic  Cerebro-Spinal  Meningitis. — In 
this  variety  the  symptoms  which  characterise  the  simple  and 
fulminant  varieties  are  combined  in  various  proportions.  In 
the  great  majority  of  cases  the  disease  follows  at  first  the 
course  of  the  simple  variety ;  but  in  from  one  to  four  days  from 


838  EPIDEMIC   CEREBRO-SPINAL  MENINGITIS. 

the  beginning  petechise  or  purpuric  spots  are  developed  more 
or  less  copiously,  and  sometimes  haemorrhage  occurs  from  the 
mucous  tracts. 

(4)  Abortive  Cerehro-Spinal  Meningitis. — During  the  height 
of  an  epidemic  cases  are  observed  in  which  the  patients  com- 
plain of  severe  headache,  stiffness  of  the  neck  or  even  slight 
retraction  of  the  head,  and  malaise  without  being  compelled 
to  desist  from  work.  Such  cases  are  justly  regarded  as  a  mild 
form  of  the  disease,  corresponding  to  the  acute  tonsillitis,  which 
is  so  common  an  accompaniment  of  epidemics  of  scarlet  fever. 

Cases  have  been  observed  in  various  epidemics  in  which  the 
symptoms  resembled  those  of  intermittent  fever  of  the  quoti- 
dian or  tertian  type ;  other  cases  have  been  noticed  in  which 
the  patient  falls  into  a  "  typhoid  condition." 

Course  and  Duration. — In  very  acute  cases  the  disease  may 
terminate  fatally  in  from  one  to  five  days,  while  abortive  cases 
may  end  in  recovery  in  the  same  time.  Cases  of  moderate 
severity  usually  begin  to  convalesce  after  one  or  two  weeks,  but 
sometimes  they  last  much  longer.  In  the  more  protracted  cases 
five  to  eight  weeks  elapse  before  the  patient  begins  to  con- 
valesce, and,  if  fatal,  death  takes  place  in  the  sixth  or  seventh 
week.  The  course  of  the  disease  towards  recovery  is  often 
interrupted  by  relapses. 

In  the  fulminant  variety  death  is  the  usual  result,  and  even 
in  mild  cases  the  mortality  is  high  owing  to  complications.  The 
rate  of  mortality  varies  very  much  in  different  epidemics.  In 
the  mildest  the  mortality  is  thirty  per  cent;  in  the  severest 
over  seventy  per  cent ;  the  average  being  about  forty  per  cent. 

Complications  and  Sequelce. — The  course  of  the  disease  is 
liable  to  be  complicated  by  intercurrent  affections.  The  most 
important  complications  are  pleurisy,  pneumonia,  bronchitis, 
pericarditis,  parotitis,  inflammation  of  the  large  joints,  bed- 
sores, affections  of  the  special  senses,  paralyses,  psychical  dis- 
turbances, and  chronic  diseases  of  the  brain  and  spinal  cord. 
The  organs  of  hearing  and  sight  are  specially  liable  to  be 
affected. 

The  auditory  lesions  may  occur  in  the  middle  ear  or  in  the 
labyrinth.  When  the  lesion  is  in  the  middle  ear  it  usually 
leads  to  perforation  of  the  membrana  tympani,  and  produces 


EPIDEMIC  CEREBRO-SPINAL   MENINGITIS.  839 

more  or  less  deafness.  Suppuration  in  the  labyrinth  affects,  as 
a  rule,  both  ears,  and  ends  in  complete  deafness.  Complete 
deafness  in  children  under  one  year  of  age  results  in  deaf- 
mutism,  and,  in  older  children,  speech,  although  previously 
acquired,  becomes  inarticulate  and  unintelligible.  Aphasia  may 
be  caused  by  the  meningitis,  but  recovery  generally  takes  place. 

The  chief  affections  of  the  eye,  which  accompany  or  follow 
epidemic  cerebro-spinal  meningitis,  are  keratitis,  iritis  with 
posterior  synechia,  choroiditis  with  detachment  of  the  retina 
and  amaurosis,  and  optic  neuritis  with  subsequent  atrophy  of 
the  nerve. 

Paralysis  of  single  nerves,  especially  of  the  cranial  nerves  or 
those  supplying  a  single  extremity,  or  general  motor  weakness, 
are  not  unfrequent  sequelae ;  but  recovery  from  these  usually 
takes  place. 

Mental  feebleness  and  impairment  of  memory,  aphasia,  and 
anarthria  have  been  observed  as  sequelae;  but  in  them  also  the 
prognosis  is,  as  a  rule,  favourable. 

Permanent  lesions  of  the  brain  and  cord,  and  their  mem- 
branes, are  often  observed,  chronic  hydrocephalus  being  the 
most  frequent. 

§  917.  Morbid  Anatomy. — The  essential  changes  found  on 
dissection  are  hyperaemia  of  the  pia  mater  of  the  brain  and 
spinal  cord,  with  more  or  less  abundant  subarachnoid  and 
interstitial  effusion  into  the  meshes  of  the  congested  mem- 
brane, consisting  either  of  serum  or  a  transparent  gelatinous 
material,  or  purulent  matter.  The  more  acute  the  course  of  the 
disease  the  less  abundant  is  the  exudation  found  between  the 
pia  mater  and  arachnoid.  In  the  fulminant  cases  exudation  is 
entirely  absent ;  but  the  pia  mater  is  found  densely  infiltrated 
with  cells,  especially  in  the  neighbourhood  of  the  vessels.  If 
the  disease  have  lasted  for  two  or  three  days,  the  exudation  is 
distinctly  purulent,  of  a  greasy,  gelatinous,  or  firmer  consistence, 
sometimes  tinged  with  blood,  and  several  lines  in  thickness.  It 
is  deposited  on  the  convexity  and  at  the  base,  especially  along 
the  course  of  the  great  vessels  in  the  Sylvian  fissure,  and  along 
the  sulci,  between  the  pons  and  chiasma,  and  on  the  pons  and 
cerebellum.     The  exudation  consists  of  pus  cells,  free  granules, 


840  EPIDEMIC   CEREBRO-SPINAL  MENINGITIS.    . 

fibrine,  and  mucine.  The  cerebral  dura  mater  is  often  tense, 
and  its  inner  surface  congested  and  adherent  to  the  arachnoid. 
The  arachnoid  is  sometimes  normal ;  at  other  times  hypersemic 
or  opaque.  The  sinuses  are  gorged  with  blood,  and  sometimes 
post-mortem  clots,  and  occasionally  decolorised  thrombi,  may 
be  found  within  them. 

The  membranes  of  the  spinal  cord  are  much  in  the  same 
condition  as  those  of  the  brain.  The  dura  mater  is  often  found 
separated  from  the  vertebrae  by  extravasated  blood,  the  arach- 
noid is  cloudy,  and  the  pia  mater  is  thickened  and  adherent  to 
the  cord.  The  exudation  appears  almost  exclusively  on  the  pos- 
terior aspect  of  the  cord,  and  the  roots  of  the  spinal  nerves  are 
frequently  bathed  in  pus.  When  the  cord  is  surrounded  by 
exudation  the  latter  is  generally  more  or  less  solid ;  it  begins  at 
an  early  period  as  a  cloudy  serum,  becoming  soon  fibrinous  and 
later  depositing  itself  as  a  thick  uniform  stratum  of  pus. 

The  substance  of  the  brain  appears  sometimes  congested  and 
there  are  punctiform  haemorrhages  and  spots  of  softening.  In 
long-continued  cases  it  is  oedematous  or  rarely  of  tough  consis- 
tence. The  ventricles  generally  contain  a  considerable  amount 
of  serum  or  a  turbid,  sero-purulent  exudation ;  the  ependyma 
and  plexuses  are  congested  and  covered  with  a  layer  of  pus. 

Of  the  other  organs  the  lungs  are  found  congested  and 
cedematous,  while  there  may  be  evidences  of  lobular  or  lobar 
pneumonia  at  the  posterior  aspects  of  the  lower  lobes. 

The  heart  is  often  flabby  and  contains  dark,  semi-fluid  blood, 
or  loose  post-mortem  coagula.  The  liver  and  spleen  are  con- 
gested, but  the  latter  organ  is  seldom  enlarged. 

§  918.  Morbid  Physiology. — The  more  prominent  symptoms 
of  epidemic  cerebro-spinal  meningitis  may  be  readily  explained 
by  the  presence  of  an  acute  inflammation  of  the  pia  mater 
of  the  spinal  cord  and  brain.  The  most  probable  origin  of  the 
disease  is  overcrowding  and  deficient  ventilation  and  drainage. 
Epidemics  of  this  disease  are  often  observed  in  malarious 
districts ;  but  malaria  probably  acts  rather  as  a  predisposing 
than  an  exciting  cause  of  the  disease. 

§  919,  Diagnosis  and  Prognosis. — During  the  prevalence  of 


EPIDEMIC  CEREBRO-SPINAL  MENINGITIS.  841 

an  epidemic  the  nature  of  the  disease  is  not  likely  to  be  mis- 
taken ;  but  it  is  more  difficult  to  recognise  it  in  isolated  cases. 
The  diagnosis  must  be  made  from  the  presence  of  the  symptoms 
just  described,  stiffness  and  pain  in  the  back  of  the  neck  being 
especially  characteristic  symptoms. 

It  may  be  laid  down  as  a  general  rule  that  in  the  fulminant 
cases  the  patient  will  die,  while  in  the  mild  and  abortive  cases 
they  are  likely  to  recover,  but  exceptions  to  this  rule  are  so 
numerous  that  the  prognosis  ought  never  to  be  made  with 
assurance.  The  following  conditions  must  be  regarded  as  of 
unfavourable  import:  Infancy  and  old  age,  extreme  symptoms 
of  excitement  and  the  early  appearance  of  those  of  depression, 
intense  cephalalgia,  loss  of  consciousness  after  apparent  im- 
provement, convulsions,  and  irregularity  of  the  respiration.  The 
mortality  in  different  epidemics  varies  from  20  to  80  per  cent. 

§  920.  Treatment. — In  the  earlier  epidemics,  cerebro-spinal 
meningitis  was  treated  as  an  acute  inflammation,  by  bleeding 
and  purgatives,  a  method  which  in  all  probability  increased  the 
fatality  of  the  malady.  Local  abstraction  of  blood  by  leeches 
to  the  temples,  or  cupping  the  nape  of  the  neck,  is  still  recom- 
mended by  some  authors  as  a  means  of  relieving  intracranial 
congestion. 

Mercury  was  at  one  time  largely  employed  as  a  means  of 
preventing  the  extension  of  the  meningeal  inflammation  and 
exudation ;  but,  although  some  authors  still  recommend  its 
cautious  use,  it  does  not  appear  that  trustworthy  evidence  has 
been  adduced  in  its  favour.  Cold  applied  to  the  head  and  spine, 
by  means  of  ice  bags,  seems  to  have  afforded  by  far  the  most 
satisfactory  results.  The  application  should  be  made  during 
the  stage  of  excitement,  and  care  should  be  taken  not  to  pro- 
long it  after  symptoms  of  depression  have  supervened. 

Of  all  internal  remedies  which  have  been  tried  opium  is  the 
most  valuable.  From  a  third  to  half  a  grain  of  morphia  may  be 
injected  subcutaneously  in  the  case  of  adults,  and  corresponding 
doses  according  to  the  age  when  children  are  affected. 

Ether  spray  to  the  back  of  the  head  and  nape  of  the  neck 
has  been  employed  with  good  effect.  Inhalations  of  chloroform 
and  large  doses  of  chloral  are  also  recommended. 


842  TETANUS. 

When  symptoms  of  depression  set  in,  the  body  should  be  sur- 
rounded with  flannel  and  hot  bottles  be  applied  to  the  feet, 
while  the  application  of  ice  to  the  head  and  spine  may  remain 
unchanged  for  a  short  time. 

Large  doses  of  quinine  have  been  employed  in  the  beginning 
of  the  disease  and  apparently  with  beneficial  results.  In  the 
rare  cases  in  which  hyperpyrexia  is  present  doses  of  from  fifteen 
to  thirty  grains  may  be  administered.  Ergot  and  belladonna 
have  been  employed,  but  with  doubtful  results. 

In  the  later  periods  of  the  disease,  and  especially  in  protracted 
cases,  iodide  of  potassium  may  be  employed  with  the  view  of  pro- 
curing absorption  of  the  exudation.  The  complications  arising 
from  affections  of  the  ears  and  eyes  must  be  subjected  to  special 
treatment,  which  need  not  be  entered  into  here.  The  diet 
should  be  regulated  according  to  the  state  of  the  fever  and 
general  symptoms. 

The  other  sequelae,  such  as  general  motor  weakness  and 
various  pareses,  may  be  treated  by  the  use  of  saline  baths,  and 
change  of  air  to  a  mountainous  district  or  the  seaside. 

(II.)  TETANUS. 

§  921.  Definition. — Tetanus  is  an  acute  affection,  charac- 
terised by  a  more  or  less  continuous  tonic  spasm  of  the  volun- 
tary muscles  with  paroxysmal  exacerbations  of  great  severity, 
during  which  the  head,  trunk,  and  lower  extremities  are  main- 
tained in  an  arched  position  owing  to  the  predominance  of  the 
action  of  the  extensor  over  the  flexor  muscles. 

§  922.  Etiology. — The  disease  may  be,  according  to  its  cause, 
divided  into  trawmatic  and  idiopathic  tetanus.  The  former 
is  much  the  more  frequent  and  important  variety,  and  is 
generally  occasioned  by  punctured,  lacerated,  or  contused 
wounds,  more  especially  gunshot  injuries.  Traumatic  tetanus 
may,  however,  occur  after  every  variety  of  wound,  and  even 
follow  contusions  without  external  abrasion,  but  it  is  rare  after 
incised  wounds. .  The  extent  and  severity  of  the  wound  does 
not  appear  to  bear  any  direct  relation  to  the  frequency  of 
tetanus ;   inasmuch  as,  in  some  cases,  the  primary  wound  is 


TETANUS.  843 

healed  and  forgotten  when  the  symptoms  of  tetanus  make 
their  appearance.  In  some  cases  a  nerve  is  involved  in  the 
cicatrix,  while  in  others  a  foreign  body  has  been  found  embedded 
in  it,  but  this  is  exceptional. 

Wounds  of  the  extremities  are  said  to  be  more  frequently 
followed  by  tetanus  tha,n  those  of  the  head,  neck,  or  trunk;  but 
the  condition  of  the  wound,  whether  it  be  healthy,  inflamed,  or 
sloaghing,  does  not  appear  to  exert  much  influence  on  the 
production  of  the  affection.  The  interval  between  the  injury 
and  'the  development  of  tetanus  varies  greatly ;  the  average 
duration  is  from  four  to  fourteen  days,  but  the  symptoms 
may  begin  a  few  hours  or  be  delayed  many  weeks  after  the 
injury.  New-born  children  are  liable  to  suffer  from  tetanus  the 
first  nine  days  after  birth ;  it  appears  to  be  connected  with  the 
separation  of  the  umbilical  cord,  and  is  therefore  of  traumatic 
origin. 

The  idiopathic  is  much  less  frequent  than  the  traumatic 
form.  The  most  usual  cause  of  idiopathic  tetanus  is  exposure 
to  cold  and  damp,  more  especially  when  the  patient  is  warm 
and  perspiring. 

A  case  of  tetanus  was  observed  by  Bright,  which  developed 
during  the  course  of  acute  rheumatism  with  pleurisy  and 
pericarditis.  At  other  times  the  disease  develops  after  abor- 
tion, but  the  condition  of  the  uterus  is  then  more  or  less 
like  that  of  an  open  wound.  In  some  cases,  where  tetanus  is 
reported  to  have  supervened  as  a  consequence  of  acute  internal 
disease,  a  careful  search  might  have  discovered  the  existence  of 
a  wound.  In  a  case  of  pneumonia  reported  by  Rosenthal  an 
enema  had  been  administered,  the  patient  complained  of  feeling 
pain  in  the  anus,  and  symptoms  of  tetanus  soon  appeared. 
At  the  autopsy  an  ulcer  of  the  rectum  was  found,  which  was 
probably  the  cause  of  the  tetanus.  Malaria  appears  to  give  rise 
to  an  intermittent  tetanus,  which  may  be  cured  by  the  adminis- 
tration of  quinine  (Coural).  Strychnine  and  other  toxic  agents 
cause  symptoms  resembling  tetanus. 

Various  influences  may  co-operate  with  external  injury  in  the 
production  of  tetanus,  and  of  these  exposure  to  cold  and  damp 
is  the  most  frequent  and  important.  Tetanus,  indeed,  occurs 
with  the  greatest  frequency  during  military  campaigns,  when 


844  TETANUS. 

the  wounded  soldiers,  after  the  heat  and  fatigue  of  battle  or  long 
marching,  are  exposed  to  cold  and  other  privations  during  the 
night. 

Tetanus  occurs  more  frequently  in  tropical  countries  than  in 
the  temperate  or  frigid  zones,  probably  owing  to  the  sudden 
alternations  of  temperature  which  are  liable  to  occur  in  the 
former,  sultry  days  being  often  followed  by  cold  nights. 

Rose  has  endeavoured  to  show  that  improper  treatment  of 
the  wounded  increases  the  proportion  of  tetanus,  and  there  is 
no  doubt  that  the  proportion  of  cases  of  tetanus  amongst  the 
wounded  is  much  less  in  the  present  day  than  in  former  times. 

The  male  is  more  frequently  affected  with  tetanus  than  the 
female  sex ;  it  is  more  frequent  in  youth  and  middle  age  than 
in  advanced  life,  and  the  robust  and  muscular  are  said  to  be 
more  frequently  attacked  than  the  feeble. 

§  923.  Symptoms. — Premonitory  symptoms  are  generally 
observed  in  tetanus  consisting  of  shivering  or  a  distinct  rigor, 
sensation  of  dragging  in  the  neck,  stiffness  in  certain  muscles, 
difficulty  of  articulation  and  deglutition,  and  yawning.  In  trau- 
matic cases  the  wound  may  become  sensitive,  and  the  patient 
complain  of  shooting  pains  radiating  from  it.  These  symptoms 
may  occur  a  few  hours  or  even  a  few  days  before  the  charac- 
teristic tonic  spasms  make  their  appearance. 

The  spasms,  as  a  rule,  begin  in  the  muscles  of  the  jaw.  At 
first  the  jaws  can  be  separated,  and  the  movements  of  chewing 
and  swallowing  be  accomplished,  although  with  difficulty. 
Soon,  however,  the  jaws  become  firmly  clenched,  constituting 
the  condition  called  trismus;  spasm  of  the  oesophagus  renders 
swallowing  of  even  a  small  quantity  of  fluid  difficult  and 
fatiguing ;  articulation  is  indistinct ;  and  the  voice  is  altered, 
partly  from  the  difficulty  of  moving  the  tongue,  and  partly  from 
implication  of  the  muscles  of  the  larynx  in  the  spasm. 

Spasm  of  the  facial  muscles  gives  to  the  countenance  a 
characteristic  expression.  The  angles  of  the  mouth  are  drawn 
outwards,  being  at  the  same  time  depressed  or  elevated,  and 
the  lips  are  often  drawn  apart  and  expose  the  set  teeth,  so  that 
the  face  assumes  a  sneering  expression,  named  the  "risus 
sardonicus."     The  nostrils  are  dilated ;  the  eyes  are  staring 


TETANUS. 


845 


and  motionless  ;  the  pupils  are  generally  contracted  ;  the  brows 
are  wrinkled  ;  and  all  the  lines  of  the  face  become  strongly 
marked,  and  give  to  the  patient  an  aged  appearance. 

The  spasm  rapidly  extends  to  the  muscles  of  the  back  of  the 
neck,  causing  retraction  of  the  head ;  while  the  erectores  spinse 
soon  become  implicated,  and  the  vertebral  column  is  then 
arched  backwards ;  the  chest  is  projected  forwards  and  rendered 
very  broad,  and  the  body  rests  on  the  back  of  the  head 
and  sacrum,  constituting  the  condition  called  opisthotonos. 
The  epigastrium  is  sunk,  and  the  abdomen  flattened,  while  the 
hardness  assumed  by  the  abdominal  muscles  is  characteristic. 
On  rare  occasions  the  body  is  said  to  be  bent  forwards,  the 
convexity  of  the  arch  being  directed  backwards,  a  condition 
named  emprosthotonos.  In  a  few  cases  the  body  is  maintained 
in  a  rigid  attitude  without  being  curved  in  any  direction,  a 
condition  named  orthotonos ;  and  in  some  rare  cases  it  is 
curved  laterally — pleurosthotonos. 

The  muscles  of  the  extremities  are  usually  not  affected  to  so 
great  an  extent  as  those  of  the  trunk,  neck,  face,  and  jaws. 

Fig.  285. 


FlO.  285  (Froim  Spence's  Surgery).— Taken  from  the  original  painting  by 
Sir  Charles  Bell. 

The  muscles  of  the  lower  extremities  are,  however,  generally  im- 
plicated to  a  greater  or  lesser  extent ;  and  during  the  spasmodic 
attack  extension,  as  a  rule,  predominates  over  flexion,  although 
flexion   at   individual  joints  has   occasionally  been    observed 


846  TETANUS. 

(Bauer).  During  the  attack  the  various  segments  of  the  lower 
extremities  are  extended  upon  one  another  and  upon  the 
trunk,  so  that  the  patient  rests  on  the  head  and  heels ;  the 
toes  are  extended  and  spread  out,  and  the  feet  are  everted. 
Even  in  severe  cases  the  muscles  of  the  upper  extremities 
may  remain  comparatively  unaffected,  but  if  passive  motion 
of  the  forearm  be  attempted,  increased  muscular  resistance 
is  readily  perceived.  When  the  spasm  extends  to  the  muscles 
of  the  upper  extremities,  flexion  predominates  over  extension  ; 
and  during  the  paroxysms  the  arms  are  drawn  close  to  the 
chest,  the  forearm  is  flexed  upon  the  arm,  the  hand  is  flexed 
at  the  wrist,  and  the  fist  is  closed,  the  palm  being  directed 
towards  the  upper  arm  (Fig.  285). 

In  some  cases  the  spasm  persists  continuously  from  the 
beginning  to  the  termination  of  the  disease ;  but,  as  a  rule,  the 
spasmodic  rigidity  of  the  muscles  occurs  in  paroxysms  with  in- 
tervals of  comparative,  but  never  complete  muscular  relaxation. 
Each  paroxysm  lasts  from  a  few  seconds  to  several  minutes,  or 
with  slight  remissions  for  hours ;  while  the  duration  of  the  free 
interval  varies  from  ten  minutes  to  hours,  but  at  other  times 
the  spasms  recur  and  remit  with  such  frequency  that  they 
assume  a  more  or  less  clonic  character.  As  the  disease  pro- 
gresses, the  paroxysms  of  spasm  recur  with  greater  frequency, 
and  muscular  contraction  is  sometimes  so  violent  that  teeth 
are  broken,  long  bones,  like  those  of  the  thigh,  fractured,  and 
large  muscles,  like  the  psoas  and  rectus  femoris,  torn  across. 
The  paroxysms  recur  spontaneously,  but  they  are  induced  by 
the  most  trivial  external  cause,  such  as  a  draught  of  air,  a 
sudden  noise,  or  an  attempt  to  swallow  or  to  administer  an 
injection.  Attempts  at  swallowing  may,  indeed,  provoke  an 
attack  so  readily  that  the  disease  may  bear  a  certain  resem- 
blance to  hydrophobia.  The  spasm  occasioned  by  the  attempt 
may  be  in  the  pharynx,  gullet,  or  in  the  cardiac  end  of  the 
stomach,  as  the  oesophagus  passes  through  the  diaphragm. 
But  wherever  it  may  be  situated,  all  attempts  at  swallowing 
are  rendered  impossible,  and  fluids  introduced  are  ejected 
through  the  nose  and  mouth,  so  that  the  patient  can  neither  be 
fed  in  the  usual  way  nor  by  the  stomach  pump.  During  the 
paroxysm  the  action  of  the  inspiratory  preponderates  over  that 


TETANUS.  847 

of  the  expiratory  muscles,  so  that  the  act  of  coughing  is  ren- 
dered impossible,  and  mucus  accumulates  in  the  bronchi.  In 
severe  paroxysms  the  chest  becomes  fixed  ;  the  countenance  is 
livid;  the  eyes  are  suffused;  the  patient  foams  at  the  mouth; 
and  is  tormented  with  a  feeling  of  dread  and  suffocation. 
Arrest  of  respiration  may  sometimes  be  caused  by  spasm  of  the 
glottis  ;  but,  as  a  rule,  it  is  the  result  of  spasm  of  the  thoracic 
muscles  and  diaphragm.  In  the  intervals  respiration  is  only 
slightly  changed  in  frequency,  from  twenty  to  twenty-four  in 
the  minute,  but  it  is  accompanied  by  a  painful  sensation  of 
increased  resistance,  requiring  effort.  Motor  paralysis  is  a  rare 
symptom  of  tetanus.  Rose  observed  paralysis  of  the  muscles  of 
one  side  of  the  face  in  a  case  in  which  the  primary  lesion  was 
in  the  area  of  distribution  of  the  facial  nerve.  General  mus- 
cular weakness,  and  paralysis  of  certain  groups  of  muscles  are 
observed  as  terminal  phenomena;  strabismus  is,  according  to 
Wunderlich,  a  precursor  of  death. 

The  sensory  disturbances  in  tetanus  are  such  as  are  usually 
produced  by  intense  muscular  cramp  in  the  muscles  of  the  calf 
Some  observers  have  noticed  an  increase  of  the  sensibility  to 
pain  independently  of  the  spasms,  while  at  other  times  the 
acuteness  of  the  senses  of  touch  and  temperature  may  be 
diminished.  Para3sthesi8e,  such  as  numbness  and  tingling, 
have  occasionally  been  observed.  Pain  is  sometimes  absent 
during  the  tetanic  seizures  ;  and  Blane  mentions  the  case  of  a 
patient  who  only  felt  a  pleasant  sensation  of  tickling  during 
the  severest  spasms.  Pain  at  the  epigastrium,  piercing  through 
the  back,  is,  according  to  some  authors,  a  pathognomonic 
symptom  of  tetanus.  It  is  present  during  both  the  tetanic 
paroxysms  and  the  intervals,  and  depends  most  probably  upon 
spasm  of  the  diaphragm. 

Psychical  disturbance  is  generally  absent  in  tetanus.  The 
mind  is  almost  always  clear  from  the  beginning  to  the  end  of 
the  disease,  although  delirium  or  coma  may  supervene  a  short 
time  before  death,  often  due  to  the  remedies  used.  Sleepless- 
ness is  one  of  the  most  troublesome  symptoms  of  acute  cases 
of  tetanus,  and  even  in  subacute  cases  sleep  is  only  obtained  at 
broken  intervals.  The  spasms  cease  during  sleep  and  the 
narcosis  of  opium  or  chloroform.     The  skin,  in  the  paroxysms 


848  TETANUS. 

and  even  intervals,  is  hot  and  bathed  in  perspiration,  having 
a  peculiar  pangent  smell,  while  the  surface  may  be  covered 
by  sudamina  as  in  other  cases  of  profuse  sweating.  In  the 
majority  of  cases  the  temperature  ranges  from  101° F.  to  103° F., 
and  may  even  rise  suddenly  to  105°  F.  in  cases  which  recover, 
although  it  is  not  maintained  long  at  this  level  only  in  fatal 
cases.  In  many  cases  there  is  hyperpyrexia  immediately  before 
death,  the  temperature  rising  to  108°  F.  or  even  110°  F,,  and  it 
may  continue  to  rise  for  some  hours  after  death. 

The  pulse  may  remain  normal  during  the  first  stage  of 
tetanus,  but  there  is  a  considerable  increase  in  its  frequency 
during  the  tetanic  seizure,  and  in  the  last  stage,  especially 
when  there  is  elevation  of  temperature,  it  may  beat  as  often 
as  180  in  a  minute.  Liston  observed  in  a  case  of  amputation 
during  tetanus  the  vessels  so  contracted  that  not  a  drop  of  blood 
had  escaped. 

The  daily  quantity  of  urine  passed  in  tetanus  is  usually  below 
the  average  in  health  ;  the  reaction  is  strongly  acid,  the  specific 
gravity  high,  and  there  is  generally  an  abundant  deposit  of 
urates  on  cooling.  Sugar  in  the  urine  in  tetanus  was  first  dis- 
covered by  Demme,  and  its  presence  has  since  been  detected 
by  others.  Senator  found  that  the  excretion  of  nitrogen  was  not 
increased  in  tetanus  as  compared  with  the  amount  excreted  by 
a  person  fasting.  He  also  states  that  the  creatinine  is  not 
increased.  There  may  be  retention  of  urine,  caused  probably 
by  spasm  of  the  sphincter,  while  at  other  times  dribbling  may 
occur  during  the  paroxysm.  The  bladder  is,  however,  never 
affected  to  so  great  an  extent  as  in  acute  spinal  meningitis. 
Spasm  of  the  sphincter  ani  is  often  present,  as  is  proved  by 
the  difficulty  of  introducing  an  enema  pipe. 

The  general  health  of  the  patient  suffers  greatly  during  the 
course  of  the  disease.  The  distorted  position  of  the  body,  the 
persistent  sleeplessness,  the  difficulty  of  respiration,  and  the 
impossibility  of  swallowing  combine  to  render  the  state  of  the 
patient  extremely  distressing.  The  bowels  are  constipated,  the 
tongue  is  generally  coated,  a  tenacious  viscid  saliva  accumulates 
in  the  mouth,  and  the  patient  may  be  excessively  hungry  and 
tormented  with  thirst,  yet  can  neither  swallow  food  nor  drink. 


TETANUS.  84-9 

§  924.  Course,  Duration,  and  Terminations. — The  time 
which  elapses  between  the  occurrence  of  an  injury  and  the  out- 
break of  tetanus  varies  greatly.  The  average  interval  is  from 
five  to  ten  days,  but  the  spasms  may  begin  a  few  hours  after 
the  injury,  or  weeks  may  intervene.  Mr.  Ward,  of  Manchester, 
has  reported  a  case  where  the  symptoms  appeared  ten  weeks 
after  the  injury. 

In  tetanus  neonatorum  the  disease  appears  from  four  to  eight 
days  after  birth,  but  it  may  sometimes  be  delayed  until  the 
fourteenth  day. 

The  intensity  of  the  disease  is  liable  to  vary  considera,bly. 
The  symptoms  in  slight  cases  may  consist  only  of  trismus  and 
some  stiffness  of  the  neck  ;  in  others  they  develop  rapidly  and 
prove  fatal  in  a  few  days,  or  occasionally  in  a  few  hours  from 
the  commencement. 

Death  takes  place  in  several  ways.  It  frequently  occurs 
during  a  paroxysm  from  asphyxia,  caused  by  rigidity  of  the 
respiratory  muscles.  In  other  cases  the  spasms  cease,  and  death 
follows  during  mild  delirium  associated  with  quick  pulse, 
high  temperature,  and  symptoms  of  asthenia.  At  other  times 
the  heart  suddenly  ceases  to  beat. 

In  cases  of  recovery  the  convulsive  attacks  become  lighter 
and  less  frequent,  and  after  a  time  entirely  cease;  if  sleep 
return,  it  is  a  favourable  sign.  The  rigidity  continues  for  some 
time  after  the  paroxysms  cease  and  then  gradually  disappears, 
though  not  in  definite  order.  Kecovery  takes  place  in  from 
one  to  eight  weeks  or  even  longer,  and  a  certain  degree  of 
weakness  and  stiffness  may  remain  in  the  muscles  for  a 
long  time. 

§  925.  Morbid  AnatoTviy. — Rigor  mortis  sets  in  almost  im- 
mediately after  death,  probably  caused  by  the  strongly  acid 
reaction  in  the  previously  active  muscles.  It  has  long  been 
suspected  that  the  morbid  changes  in  tetanus  are  to  be  found 
in  the  central  nervous  system,  and  more  especially  in  the  spinal 
cord.  In  the  earlier  records,  the  changes  most  frequently  men- 
tioned are  congestion  and  extravasations  of  blood  into  the  cord 
and  its  membranes,  and  occasionally  softening  of  the  former. 
Rokitansky  was  the  first  to  subject  the  spinal  cord  to  micro- 
ccc 


850  TETANUS. 

scopic  examination  in  cases  of  tetanus.  He  found  an  increase 
of  nuclei,  destruction  of  the  medullary  substance,  agglomerations 
of  fat  granules,  and  amyloid  bodies.  He  also  observed  similar 
changes  in  the  peripheral  nerves.  Leyden,  however,  has  since 
proved  that  the  changes  found  by  Rokitansky  are  not  constant, 
being  in  great  measure  due  to  imperfect  methods  of  pre- 
paration. Lockhart  Clarke  found  great  hypersemia  of  the  cord 
and  its  membranes,  as  well  as  centres  of  softening,  in  the  grey 
and  white  substance,  and  similar  changes  have  been  described 
by  Dickson,  Allbutt,  Coats,  and  other  observers. 

In  the  spinal  cord  of  a  patient  dead  of  tetanus,  I  found 
marked  softening  in  the  lumbar  region,  A  section  from  the 
middle  of  the  lumbar  region  is  shown  in  Plate  V.,  fig.  6.  A 
vessel  from  the  anterior  fissure,  represented  in  Plate  Y.,  fig.  7, 
was  seen  to  be  surrounded  by  leucocytes,  and  the  whole  of  both 
grey  and  white  substances  was  densely  infiltrated  with  the  same, 
although  not  usually  aggregated  in  the  perivascular  spaces  and 
around  the  vessels  as  in  hydrophobia.  Another  vessel  from  the 
grey  substance,  cut  obliquely,  is  shown  in  Plate  V.,  fig.  8,  the 
lymph  sheath  of  which  is  filled  with  leucocytes.  The  most  in- 
teresting changes  were  observed  in  the  ganglion  cells  of  the 
anterior  horns,  A  few  cells  of  normal  size  were  seen  in  the 
portion  of  the  median  group  nearest  the  anterior  fissure,  the 
greater  portion  of  the  cells  of  the  antero-lateral  group  and  a 
few  of  those  of  the  postero-lateral  group  were  also  of  normal 
size ;  but  most  of  the  cells  of  the  median  group,  and  the  mar- 
ginal cells  of  the  other  groups,  had  apparently  disappeared, 
when  the  section  was  examined  with  a  low  power.  The  disap- 
pearance of  these  cells  was,  however,  not  real ;  under  a  high 
power,  they  could  be  seen  shrunk  in  their  cavities.  Similar 
changes,  although  less  in  extent,  were  found  in  other  three  cases 
examined  by  me.  Shrinking  of  some  of  the  ganglion  cells  of 
the  anterior  horns  has  been  recently  observed  by  Dr.  Harris 
and  Mr.  Doran. 

With  respect  to  the  medulla  oblongata  in  the  cases  examined 
by  me,  the  cells  in  the  internal  and  anterior  portions  of  the 
nucleus  of  the  hypoglossal  were  considerably  altered,  while  those 
of  the  body  of  the  nucleus  appeared  normal.  The  cells  of  the 
nuclei  of  the  spinal  accessory,  and  pneumogastric,  appeared 


TETANUS.  851 

always  to  suffer ;  while  the  longitudinal  vessel,  which  lies  in  the 
deepest  part  of  the  floor  of  the  fourth  ventricle,  is,  as  remarked 
by  Dr.  Coats,  usually  surrounded  by  red  blood  corpuscles.  The 
nucleus  of  the  facial,  the  motor  nucleus  of  the  fifth,  the  nucleus 
of  the  abducens,  and  that  of  the  third  and  fourth  cranial 
nerves  appeared  normal.  A  large  number  of  leucocytes  were 
observed  in  the  olivary  bodies,  the  brachium  of  the  pons,  and 
between  the  fibres  of  the  seventh  nerves. 

In  the  roots  of  the  fifth  nerve,  proceeding  from  the  cere- 
bellum, large  vessels  were  observed  which  were  distended  with 
red  blood  corpuscles,  and  the  whole  of  the  surrounding  tissue 
was  densely  infiltrated  with  leucocytes.  .  The  corpus  dentatum 
of  the  cerebellum  and  the  white  substance  subjacent  to  the 
cortex,  were  also  densely  infiltrated  with  leucocytes  and  inter- 
sected with  distended  blood-vessels  to  an  extent  which  it  is 
impossible  to  regard  as  other  than  the  result  of  disease.  The 
cells  of  Purkinje  were  surrounded  with  leucocytes,  but  did  not 
themselves  present  any  decided  morbid  appearances. 

In  traumatic  tetanus  the  older  reports  state  that  marked 
changes  were  frequently  seen  at  the  seat  of  the  wound.  Nerves 
were  crushed  and  torn,  foreign  bodies  buried  in  the  nerve  trunks, 
and  inflammation  and  thickening  were  found  about  the  injury. 
Lepelletier  was  the  first  to  describe  the  occurrence  of  an  ascend- 
ing neuritis  in  a  patient  who  died  from  tetanus.  Froriep  found 
red  spots  and  swellings  of  the  nerves  alternating  with  parts 
which  remained  healthy,  these  changes  extending  from  the 
seat  of  injury  to  the  spinal  cord. 

Evidences  of  inflammation  have  been  described  by  Aronssohn, 
Dupuy,  and  Andral  in  the  sympathetic  nerves,  especially  in  the 
cervical  and  semilunar  ganglia. 

The  voluntary  muscles  are  generally  of  a  pale  colour,  and 
ruptures  of  bundles  of  fibres  with  extravasations  of  blood  have 
been  found.  Fatty  degeneration  of  the  muscles  has  also  been 
observed. 

§  926.  Pathology. — The  pathology  of  tetanus  is  not  very 
clear,  but  a  few  landmarks  for  future  researches  have  been 
ascertained.  Morbid  alterations  have  been  found  in  various 
portions  of  the  cord  and  medulla  oblongata.     Whatever  morbid 


852  TETANUS. 

process  these  changes  may  indicate,  they  are  doubtless  accom- 
panied by  breaking  down  of  the  structure  of  the  cord,  and 
during  the  disintegrative  process  the  molecules  of  the  proto- 
plasm of  the  cells  or  of  the  axis-cylinders,  or  of  both,  fall 
from  an  unstable  to  a  stable  position,  the  latent  energy 
being  rendered  active.  During  this  process  the  irritability 
\)f  the  grey  matter  and  of  the  nerve  fibres  is  increased,  while 
there  is  a  decrease  of  their  resistance  to  conduction.  In  con- 
sequence of  the  increased  irritability  and  diminished  resistance, 
the  slightest  peripheral  irritation  will  determine  muscular 
spasms  by  setting  free  a  relatively  large  amount  of  energy. 
Indeed,  Romberg  regards  the  increased  reflex  irritability  as 
the  chief  element  in  tetanus,  but  it  must  be  remembered  that 
spasms  may  be  caused  by  the  pathological  process  going  on  in 
the  cord  independently  of  peripheral  irritation. 

An  ascending  neuritis  has  been  found  in  some  cases  in  the 
nerve  leading  from  the  wound  to  the  cord ;  and  it  is  possible 
that  in  all  cases  there  is  a  progressive  extension  of  the  diseased 
process  from  the  external  wound  towards  the  centre.  But  the 
morbid  changes  in  tetanus  are  not  limited  to  the  peripheral 
nerves,  spinal  cord,  and  medulla  oblongata,  but  probably 
extend  to  the  cerebellum.  I  am  inclined  to  believe  with 
Dr.  Hughlings-Jackson  that  discharges  of  nerve  energy  from 
the  cortex  of  the  cerebellum  are  the  main  cause  of  the  paroxysms 
of  spasm  in  tetanus,  although  these  discharges  may  to  some 
extent  be  determined  by  the  instability  of  centres  in  the  medulla 
oblongata  and  spinal  cord. 

§  927.  Diagnosis. — The  diagnosis  in  well-marked  cases  pre- 
sents no  difficulty,  but  the  obscure  symptoms  of  the  early 
stage  may  be  overlooked  or  their  importance  under-estimated. 
In  the  tetanus  of  strychnia  the  masticatory  muscles  are  rarely 
attacked  first,  and  may  possibly  escape  altogether ;  the  symp- 
toms are  well  marked  at  the  commencement,  and  reach  their 
full  development  in  a  few  minutes ;  opisthotonos  is  a  very  early 
symptom ;  there  are  usually  intervals  of  complete  intermission  ; 
and  death  occurs  commonly  in  less  than  three  hours,  or  else 
recovery  is  very  rapid. 

Masticatory    spasm    induced    by   decayed    teeth,    hysteria, 


TETANUS.  853 

and  otlier  causes,  and  stiffness  of  the  jaws  from  tonsillitis, 
parotitis,  and  disease  of  the  articulations  of  the  jaw,  may 
be  mistaken  for  the  first  stage  of  tetanus;  but  even  in  slight 
cases  of  tetanus  the  cervical  muscles  are  to  some  extent  affected, 
and  if  attention  be  paid  to  the  symptoms  of  the  former  diseases, 
they  cannot  well  be  mistaken  for  the  latter. 

Hysterical  spasms  may  sometimes  closely  simulate  tetanus, 
but  in  hysteria  an  interval  of  variable  duration  follows  the 
paroxysm,  in  which  the  muscles  are  relaxed,  and  other  symptoms 
indicative  of  hysteria  are  present. 

§  928.  Prognosis. — The  prognosis  in  tetanus  is  always  grave. 
Most  authors  regard  idiopathic  tetanus  as  being  less  dangerous 
than  the  traumatic  variety. 

It  may  be  laid  down,  as  a  general  rule,  that  the  longer  the 
interval  which  elapses  between  the  injury  and  the  appearance 
of  tetanus  the  more  likely  is  the  disease  to  become  chronic  and 
to  end  favourably.  Acute  cases,  in  which  the  spasms  supervene 
soon  after  the  injury,  and  recur  with  increasing  violence  and 
at  decreasing  intervals,  are  almost  always  fatal,  death  taking 
place  in  a  few  days,  or  even  hours,  from  the  commencement.  The 
aphorism  of  Hippocrates,  that  tetanus  ends  in  recovery  if  the 
patient  survive  the  fourth  day  of  the  disease,  may  be  accepted 
as  practically  true,  although  there  are  many  exceptions. 

Special  symptoms  are  relied  upon  by  some  authors  in  forming 
a  prognosis.  The  prognosis  is  said  to  be  grave  when  attempts 
to  swallow  during  the  first  few  days  induce  suffocative  attacks. 
Wunderlich  regards  the  occurrence  of  strabismus  as  of  fatal 
augury,  and  a  frequent  pulse  and  high  temperature  belong  to 
the  terminal  phenomena  of  the  affection. 

§  929.  Treatment. — At  one  time  tetanus  was  regarded  as  an 
inflammatory  disease,  and  treated  accordingly  by  so-called  anti- 
phlogi sties,  blood-letting,  and  mercurials  ;  but  this  method  of 
treatment  has  been  abandoned  along  with  the  theory  upon 
which  it  was  founded.  It  is  needless  to  point  out  here  how 
necessary  it  is  in  surgical  practice  to  protect  all  wounds  from 
unfavourable  influences  both  in  the  local  treatment  of  the  wound 
and  in  the  general  surroundings  of  the  patient. 


854  TETANUS. 

Different  expedients  have  from  time  to  time  been  proposed 
with  the  view  of  arresting  the  peripheral  irritation  caused  by 
the  primary  injury.  Amputation  of  the  limb  and  section  of 
the  nerves,  at  one  time  recommended,  are  now  abandoned  for 
the  safer  and  apparently  more  successful  operation  of  nerve 
stretching. 

The  next  aim  of  treatment  is  to  diminish  the  irritability  of 
the  cord.  Chloral  hydrate  is  probably  superior  to  any  other 
remedy  for  this  purpose. 

Cannabis  Indica  has  been  used,  but  it  is  too  uncertain  in  its 
results,  and  its  physiological  action  is  not  yet  well  ascertained. 
Calabar  bean  or  physostigmin  has  been  employed  with  occa- 
sional success.  Tobacco  or  nicotine  is  highly  recommended  by 
Curling,  but  the  depression  it  produces  is  sometimes  alarming 
and  may  be  dangerous.  Bromide  of  potassium  diminishes 
reflex  irritability,  and  may  be  used  either  alone  or  in  combina- 
tion with  chloral. 

Curara,  belladonna,  and  prussic  acid  have  been  employed  in 
the  treatment  of  tetanus  with  the  view  of  controlling  the 
spasms,  but  the  course  of  the  central  disease  is  unaffected  by 
arrest  of  the  spasms. 

The  cold  bath  and  cold  douche  may  be  used  when  there  is 
a  sudden  elevation  of  temperature,  and  under  these  circum- 
stances the  patient  may  be  placed  in  a  bath  of  about  90°  F., 
the  temperature  of  which  is  rapidly  reduced  to  60°  F.  by  the 
gradual  addition  of  cold  water. 

In  ordinary  cases  the  luarm  bath  is  exceedingly  soothing  to 
the  patient,  and  for  this  reason  it  forms  a  pleasant  auxiliary 
to  other  treatment.  The  vapour  bath  has  been  used,  but  is 
inferior  to  the  warm  bath. 

The  patient  should  be  protected  from  every  source  of  irrita- 
tion, such  as  noises,  strong  light,  changes  in  temperature, 
and  sudden  touching  of  any  part  of  the  body.  His  strength 
should  be  well  supported,  and  when  spasm  does  not  permit 
the  patient  to  swallow  liquids,  food  should  be  introduced  by 
means  of  a  tube  passed  through  the  nose  after  the  patient  has 
previously  been  brought  under  the  influence  of  chloroform. 
Nutritive  enemata  may  also  be  employed. 

Constipation  is  a  troublesome  symptom,  and  may  require 


H7DR0PH0BIA.  855 

attention  ;  but  less  irritation  is  caused  by  the  contact  of  fseces 
in  the  bowels  to  which  they  are  accustomed  than  by  the  irrita- 
tion produced  by  powerful  cathartics. 

A  few  trials  have  been  made  with  electricity  in  the  treatment 
of  tetanus,  but  the  results  have  not  been  encouraging, 

(III.)  HYDROPHOBIA. 
§  930.  Definition. — Hydrophobia  is  a  disease  caused  by  the 
.inoculation  of  a  specific  animal  poison  contained  in  the  saliva 
of  animals  under  its  iufluence,  the  most  characteristic  clinical 
features  in  man  being  excitement  and  spasms  induced  by 
attempts  to  swallow  fluids. 

§  931.  Etiology. — The  cause  of  hydrophobia  appears  to  be  in 
all  cases  a  specific  virus  contained  in  the  secretions  of  the  mouth 
of  the  infected  animal,  and  the  disease  is  communicated  to  man, 
and  probably  to  other  animals  also,  only  by  direct  inoculation 
through  a  bite.  There  are  no  grounds  for  believing  that  canine 
rabies  ever  arises  spontaneously,  and  it  is  probably  in  all  in- 
stances communicated  from  one  animal  to  another  by  means  of 
a  bite.  The  animals  which  are  capable  of  inoculating  man  are 
the  dog,  wolf,  fox,  badger,  marten,  cat,  horse,  sheep,  pig,  and 
goat  (Gamgee).  Only  a  small  proportion  of  human  beings 
bitten  by  rabid  animals  become  affected  with  hydrophobia,  a 
proportion  which  has  been  variously  estimated  at  from  5  to  50 
per  cent.  The  number  which  become  subsequently  affected  with 
the  disease  is  greater  when  the  exposed  parts  of  the  body  are 
bitten.  It  is  probable  that  the  teeth  in  passing  through  the 
clothes  are  often  cleansed,  so  that  the  w^ound  escapes  inocula- 
tion. It  is  likely  that  a  considerable  proportion  of  those  bitten 
are  protected  by  the  cauterisation  and  other  local  treatment  to 
which  the  wound  is  usually  subjected  at  the  time.  Some 
individuals  appear  to  possess  a  relative  or  complete  immunity 
from  the  disease,  and  it  is  transmitted  irrespectively  of  age,  sexr 
or  constitution. 

§  932.  Symptoms. — The  period  of  incubation  in  hydrophobia 

is  longer,  and  liable  to  greater  variations  in  its  duration,  than 
that  of  any  other  specific  disease.     In  the  majority  of  cases  the 


85G  HYDROPHOBIA. 

symptoms  manifest  themselves  from  four  to  eight  weeks  after 
the  injury,  but  they  may  occasionally  appear  at  the  end  of  the 
first  week  or  not  until  nine  months,  and  on  rare  occasions  not 
until  several  years  have  elapsed. 

The  outbreak  of  the  characteristic  manifestations  of  h^^^dro- 
phobia  is  often  preceded  for  a  day  or  two  by  premonitory 
symptoms.  The  wound  inflicted  by  the  bite  becomes  intensely 
painful,  and  the  pains  generally  extend  along  the  nerves  towards 
the  trunk,  If  the  wound  has  not  healed,  it  assumes  an  un- 
healthy character ;  if  it  has  closed,  the  cicatrix  becomes  red  and 
irritable.  During  the  period  of  invasion  the  patient  suffers 
from  chilliness  and  general  malaise,  the  pulse  is  rapid,  the 
respirations  are  quick  and  sighing,  there  is  thirst  and  anorexia, 
and  even  in  this  stage  the  patient  may  manifest  a  disinclination 
to  swallow  fluids.  The  face  is  pale  and  has  an  anxious  expres- 
sion; the  patient  is  fidgetty,  restless,  and  peevish;  while  de- 
pression of  spirits  is  so  constant  and  marked  a  symptom  that 
the  period  of  invasion  has  been  called  the  melancholic  stage 
of  the  disease. 

At  the  end  of  a  few  hours,  or  at  most  a  day  or  two,  the 
characteristic  features  of  the  disease  become  fully  developed. 
The  patient  complains  of  stiffness  about  the  head  and  neck,  his 
mouth  and  fauces  are  congested,  and  he  suffers  from  agonising 
thirst,  while  every  attempt  to  swallow  induces  a  violent  spasm 
of  the  pharyngeal  and  respiratory  muscles,  which  often  extends 
to  the  muscles  of  the  entire  body,  and  throws  the  patient  into 
a  condition  of  intense  excitement  and  alarm. 

The  patient  at  first  may  be  able  to  swallow  some  liquid.  In 
the  cases  that  have  come  under  my  observation  the  patient 
in  the  early  stage  of  the  disease  on  being  asked  to  drink  took 
hold  of  the  vessel,  looked  at  it  doubtfully  for  some  time,  and 
then,  with  horror  depicted  on  his  face,  asked  for  it  to  be  taken 
away.  Soon  afterwards  he  would  summon  up  sufficient  resolu- 
tion to  ask  to  drink  again,  and  after  a  period  of  deliberation  and 
apparent  preparation  for  a  supreme  effort  the  vessel  was  carried 
rapidly  to  the  mouth,  generally  with  both  hands,  and  part  of  its 
contents  swallowed  with  the  utmost  precipitancy  and  agitation, 
the  vessel  being  then  almost  flung  from  the  hands.  This  period, 
however,  is  of  short  duration.     Every  attempt  to  swallow  liquid 


HYDROPHOBIA.  857 

is  found  to  induce  a  severe  spasmodic  paroxysm,  and  the 
abhorrence  of  water  becomes  so  intense  that  the  spasm  may  be 
excited  by  the  sight  of  it,  or  even  by  the  noise  occasioned  by 
pouring  it  from  one  vessel  to  another.  A  viscid  saliva  now 
accumulates  in  the  mouth,  which  the  patient  is  constantly 
attempting  to  spit  out,  giving  rise  to  the  sound  which  has  often 
been  described  as  a  bark.  During  the  course  of  the  disease 
convulsive  movements  may  occur  in  the  face,  jaw,  neck,  trunk, 
and  extremities,  the  spasms  being  sometimes  not  unlike  tetanic 
seizures. 

The  sensory  disturbances  consist  of  hypersesthesia  of  general 
sensibility  and  the  special  senses.  The  patient  often  complains 
of  the  weight  of  the  bed-clothes,  he  shuns  the  light  or  luminous 
objects,  and  is  distressed  by  the  slightest  noise.  Patients  also 
complain  of  painful  sensations  in  the  head,  neck,  back,  and 
epigastrium,  as  well  as  in  the  neighbourhood  of  the  primary 
wound. 

The  reflex  excitability  is  greatly  increased,  and  a  draught  of 
cold  air  on  the  surface  of  the  body,  especially  on  the  face, 
may  determine  a  spasmodic  attack  of  great  severity.  The 
slightest  impression  on  the  surface  of  the  body  occasions,  as 
has  been  pointed  out  by  Dr.  Gowers,  a  spasm  of  the  costo- 
superior  respiratory  muscles  and  erectores  spinse,  very  similar 
to  that  produced  by  the  cold  affusion  in  healthy  individuals. 
The  pulse  is  small  and  frequent  from  the  beginning,  and  be- 
comes thready,  irregular,  and  uncountable  towards  the  fatal 
termination;  and  the  urine  frequently  contains  albumen  and 
sugar.  Out  of  five  cases,  in  the  Manchester  Royal  Infirmary, 
and  reported  by  Mr.  Southam,  the  urine  was  saccharine  in  three, 
and  highly  albuminous  in  all  of  them. 

Psychical  disturbances  are  always  present  in  hydrophobia, 
although  they  are  much  more  prominent  in  some  cases  than 
in  others.  They  vary  from  a  certain  emotional  excitement 
that  may  be  mistaken  for  ordinary  hysteria  to  a  state  of  acute 
maniacal  delirium,  the  latter  being  specially  liable  to  occur  in 
children.  In  the  majority  of  cases  the  patient  has  a  wild  and 
agitated  look ;  his  eyes  are  bright  and  restless ;  his  brows 
wrinkled ;  and  his  countenance  assumes  an  expression  of  ex- 
treme horror.  The  patient  is  restless,  sleepless,  often  loquacious, 


858  HYDROPHOBIA. 

and  all  his  movements  are  characterised  by  great  precipitation. 
The  intellect  may  remain  more  or  less  clear  for  a  time,  but 
towards  the  end  he  begins  to  wander,  and  hallucinations  or 
attacks  of  violent  maniacal  excitement  supervene,  during  which 
the  patient  may  injure  himself  or  the  attendants.  In  children 
the  symptoms  of  acute  mania  may  predominate  from  the  first. 
In  the  case  of  a  child  four  and  a  half  years  of  age  under  the 
care  of  Mr.  Ewart,  in  St.  Mary's  Hospital,  Manchester,  the 
maniacal  symptoms  were  early  manifested.  During  the  maniacal 
paroxysms,  terror,  caused  probably  by  hallucinations  of  sight, 
appeared  to  be  the  predominant  symptom,  and  the  child 
screamed  to  his  mother  to  save  him  from  the  "  pussy  "  that  was 
threatening  to  attack  him  (he  had  been  bitten  five  weeks  pre- 
viously in  the  face  by  a  rabid  cat),  and  struggled  violently  to 
escape  from  his  attendants. 

As  the  disease  progresses  to  a  fatal  termination  all  the 
symptoms  are  aggravated,  and  the  pulse  becomes  rapid,  irregular, 
and  thready;  tenacious  mucus  accumulates  in  the  mouth  and 
is  expelled  with  difficulty,  the  voice  becomes  hoarse,  and  the 
spasmodic  paroxysms  increase  in  severity  and  frequency.  An 
attack  of  convulsions  or  profound  coma  may  precede  the  fatal 
termination,  but  it  is  rare  to  observe  a  case  uninfluenced  by 
narcotics.  Death  may  take  place  suddenly  from  asphyxia  during 
a  convulsive  attack,  or  from  exhaustion.  In  some  cases  the 
spasms  gradually  diminish  and  may  cease  a  few  hours  before 
death  ;  the  patient  may  even  become  able  to  drink,  but  this 
comparative  calm  is  deceptive,  and,  instead  of  being  a  sign  of 
recovery,  is  only  the  precursor  of  death. 

§  933.  Course,  Duration,  Terminations. — When  once  the 
disease  is  fully  established  it  pursues  a  rapid  course,  and  ter- 
minates probably  always  fatally  in  from  two  to  four  days  after 
the  commencement  of  the  symptoms. 

§  934.  Morbid  Anatomy. — In  the  older  records  of  post- 
mortem examinations  in  cases  of  death  from  hydrophobia  the 
chief  alterations  of  the  nervous  system  mentioned  are  congestion 
of  the  brain,  medulla  oblongata,  and  spinal  cord  and  of  their 
membranes.     In  1869  Meynert  made  a  microscopic  examina- 


HYDROPHOBIA.  859 

tion  of  portions  of  the  brain  and  spinal  cord  of  two  patients 
who  had  died  of  hydrophobia;  but  the  changes  observed  by 
him,  in  addition  to  congestion  of  the  spinal  cord  and  brain, 
were  somewhat  indefinite.  Soon  afterwards  Dr.  Mlbutt  made 
some  important  observations.  "In  the  cerebral  convolutions 
the  mesocephalon,  the  pons,  medulla,  and  spine,  the  vessels,"  he 
says,  "  were  seen  in  various  degrees  of  distension,  and  in  many 
places  the  walls  were  obviously  thickened,  and  here  and  there 
in  them  were  patches  of  incipient  nuclear  proliferation."  These 
observations  were  confirmed  by  Hammond,  who  also  found 
changes  in  the  ganglion  cells  of  the  nuclei  of  origin  of  the 
pneumogastric  and  hypoglossal  nerves,  as  well  as  in  those  of 
"  the  first  and  second"  layers  of  the  cortex  of  the  cerebrum.  The 
nuclear  proliferation  described  by  Dr.  Allbutt  as  occurring  in 
the  walls  of  the  distended  vessels  consists,  as  was  subse- 
quently pointed  out  by  Benedikt,  of  migrated  white  blood 
corpuscles. 

In  the  brains  of  dogs  affected  with  rabies,  Benedikt  found  the 
white  blood  corpuscles  aggregated  around  the  vessels  to  such  an 
extent  as  to  form  what  he  termed  a  miliary  abscess.  He  found 
similar  appearances  in  the  brain  of  a  human  subject  who  had 
died  of  hydrophobia.  The  spinal  cord  and  medulla  oblongata 
were  not  examined  in  these  cases.  These  observations  have 
been  confirmed  and  extended  by  Coats  and  Gowers,  who  found 
accumulations  of  leucocytes  around  the  smaller  vessels  of  the 
medulla  oblongata,  spinal  cord,  basal  ganglia,  and  cortex  of  the 
brain.  Small  extravasations  of  blood  were  occasionally  observed 
in  the  neighbourhood  of  the  distended  vessels,  while  Coats 
found  migrations  of  leucocytes  in  the  salivary  glands,  mucous 
glands  of  the  larynx,  and  kidneys.  Marochetti  observed  pustules 
on  the  frenum  linguae  during  the  first  few  days  of  the  period  of 
incubation.  In  the  case  of  a  dog  that  died  of  rabies  I  found 
miliary  abscesses  extensively  distributed  through  the  spinal  cord, 
medulla  oblongata,  basal  ganglia,  and  cortex  of  the  brain.  In 
addition  to  the  aggregation  of  leucocytes  around  the  vessels, 
Gowers  describes  intravascular  changes,  consisting  of  the  pre- 
sence of  clots  in  some  of  the  vessels,  which  he  thinks  must 
have  formed  during  life. 

The  following  description  is  derived  from   my  own  micro- 


860 


I 


DESCRIPTION     OF    PLATE    V. 
(From  Drawings  hy  Dr.  A.  H.  Young.) 

Fig.  1. — Section  of  medulla  oblongata  from  a  case  of  hydrophobia,  showing 
extensive  infiltration  of  the  tissues  with  leucocytes  ;  all  the  cut  vessels  being 
surrounded  by  them.  The  nucleus  of  the  hypoglossal  nerve  is  infiltrated  with 
leucocytes ;  but  its  cells  are  apparently  healthy.  Almost  all  the  cells  of  the 
nucleus  of  the  pneumogastric  nerve  have  disappeared,  and  the  nucleus  of  the 
spinal  accessory  nerve  was  similarly  afltected  lower  down  the  medulla. 

Fig.  2. — Portion  of  the  nucleus  of  the  hypoglossal  nerve  from  same  section  as 
Fig.  1,  under  a  higher  magnifying  power.  The  ganglion  cells  appear  healthy, 
although  they  are  surrounded  by  leucocytes.  The  cut  ends  of  the  vessels  may  be 
seen  surrounded  by  numerous  leucocytes. 

Fig.  3. — Portion  of  grey  matter  of  olivary  body  from  same  section  as  Fig.  1, 
magnified,  showing  infiltration  with  leucocytes. 

Fig.  4. — Section  of  the  anterior  horn  of  the  grey  substance  of  the  cervical 
enlargement  of  the  spinal  cord  in  a  case  of  hydrophobia,  m.  Median ;  al.  Antero- 
lateral ;  pi,  Postero-lateral ;  and  c.  Central  group  of  ganglion  cells.  Shows 
infiltration  of  the  tissues  with  leucocytes,  and  the  cut  vessels  surrounded  by  them. 
The  ganglion  cells  have  apparently  disappeared  from  the  area  which  lies  between 
the  median  and  the  antero-lateral  groups,  and  only  two  or  three  of  the  cells  of 
the  central  group  are  seen ;  while  some  cells  have  also  apparently  disappeared 
from  the  margins  of  the  antero-lateral  and  postero-lateral  groups.  The  central 
group  was  also  infiltrated  with  red  blood  corpuscles. 

Fig.  5. — Portion  of  the  area  from  which  the  cells  had  apparently  disappeared 
in  Fig.  4,  magnified.  Shows  that  the  cells  are  still  present,  although  they  are 
much  shrunk,  and  some  of  their  processes  destroyed.  The  walls  of  the  cavity 
surrounding  them  are  infiltrated  with  leucocytes  or  covered  by  nuclei. 

Fig.  6. — Tetanus.  Section  of  the  anterior  horn  of  grey  substance  from  the 
middle  of  the  lumbar  enlargement.  Showing  infiltration  of  the  tissue  with 
leucocytes,  and  apparent  disappearance  of  the  ganglion  cells  from  the  area  lying 
between  the  few  remaining  cells  of  the  median  group  and  those  of  the  antero- 
lateral group  ;  also  apparent  disappearance  of  a  considerable  portion  of  the  cells 
of  the  postero-lateral  group. 

Fig.  7. — Vessel  from  the  anterior  median  fissure  from  the  same  section  as 
Fig.  6,  surrounded  by  numerous  leucocytes. 

Fig.  8. — Vessel  cut  obliquely  from  the  grey  substance  from  the  same  section  a 
Fig.  6,  showing  its  lymph  sheath  surrounded  by  leucocytes. 


Plale ,  V. 


Fi,^.    1. 


Fig     2. 


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r-intem.  ]it.K 


HYDROPHOBIA.  861 

scopical  examination  of  the  nervous  system  from  six  cases  of 
hydrophobia : — 

The  changes  observed  in  the  medulla  oblongata  in  hydrophobia  corre- 
sponded closely  to  the  careful  drawings  and  accurate  description  of  Dr. 
Gowers  ;  except,  perhaps,  with  respect  to  his  description  of  the  clot  within 
the  blood-vessels.  The  distribution  of  these  vascular  and  perivascular 
changes  in  the  medulla  oblongata  was,  in  one  of  my  cases,  almost  coexten- 
sive with  the  distribution  of  the  vessels.  The  grey  matter  on  the  floor  of 
the  fourth  ventricle  was  most  affected,  probably  because  it  is  the  most 
vascular  ;  but  similar  changes  were  found  in  the  formatio  reticularis, 
oHvary  bodies,  restiform  bodies,  and  to  a  less  extent  in  the  anterior  pyra- 
mids. The  condition  of  the  medidla  in  this  case  is  shown  in  Plate  V.,  fig.  1. 
It  will  be  observed  that,  although  the  nucleus  of  the  hyjjoglossal  is  infil- 
trated with  leucocytes,  its  own  cells  are  not  much  affected,  while  scarcely  a 
trace  is  left  of  those  belonging  to  the  spinal  accessory  and  pneumogastric 
nuclei.  The  same  condition  is  shown  under  a  higher  magnifying  power  in 
fig.  2,  in  which  the  cells  of  the  nucleus  of  the  hypoglossal  appear  healthy, 
although  the  tissue  is  densely  infiltrated  with  leucocytes.  Infiltration  of 
the  grey  matter  of  the  ohvary  bodies  with  leucocytes  is  shown  in  fig.  3. 
Similar  vascular  and  perivascidar  changes  were  observed,  though  to  a 
less  extent,  throughout  the  whole  extent  of  the  pons,  in  the  grey  sub- 
stance surroimding  the  aqueduct  of  Sylvius,  and  in  the  corpora  quadri- 
gemina,  as  has  already  been  described  by  Dr.  Coats.  The  cortex  of  the 
brain  and  subjacent  white  substance  were  infiltrated  with  leucocytes,  and 
the  pyramidal  cells  of  the  fourth  layer  of  the  cortex  were  often  partially 
filled  with  small  yellow  granules.  The  cortex  of  the  cerebellum  and 
subjacent  white  substances  were  also  much  infiltrated  with  leucocytes, 
the  changes  here  being  almost,  if  not  quite,  as  marked  in  extent  as  in 
the  brain,  and  the  cells  of  Purkinje  were  very  granular.  It  would  appear, 
therefore,  that  hydrophobia  is  a  disease  of  a  very  diffused  character. 

The  changes  found  in  the  spinal  cord  in  hydrophobia  deserve  special 
mention.  They  are  not  always  well  marked,  and  in  three  of  my  cases 
might  very  readily  be  overlooked,  while  in  the  other  three,  marked 
alterations  were  observed  in  the  upper  dorsal  region  and  in  the  cervical 
enlargement.  One  of  the  anterior  horns,  from  a  section  of  the  cervical 
enlargement,  is  represented  by  Dr.  Young  in  fig.  4.  The  whole  of 
the  grey  substance  is  infiltrated  with  leucocytes,  and  the  vessels  on  each 
side  of  the  central  canal  are  surrounded  by  them.  The  branches  of  the 
anterior  external  and  anterior  lateral  arteries  distributed  to  the  grey 
substance  are  surrounded  by  leucocytes.  Three  distinct  miliary  abscesses 
were  observed  in  the  external  margin  of  the  antero-lateral  group  of  cells 
in  the  cord  taken  from  the  child,  who  died  of  hydrophobia,  under  the  care 
of  Mr.  Ewart. 

The  most  interesting  changes  probably  have  occurred  in  the  ganglion 
cells  themselves.     Two  or  three  cells,  of  normal  size,  may  be  observed  in 


862  HYDROPHOBIA. 

the  part  of  the  median  group  which  is  nearest  to  the  anterior  fissure,  and 
full-sized  cells  may  also  be  observed  in  the  central  portion  of  the  antero- 
lateral and  postero-lateral  groups.  When  examined  under  a  low  power, 
all  the  cells  seem  to  have  disappeared  from  the  territory  which  lies  between 
the  few  remaining  cells  of  the  median  group  (fig.  4,  m)  and  the  antero- 
lateral group  (fig.  4,  a  1),  while  the  cells  of  the  central  group  (fig.  4,  c) 
have  also,  with  the  exception  of  two  or  three,  disappeared,  and  a  con- 
siderable number  are  wanting  also  along  the  margins  of  the  antero-lateral 
and  postero-lateral  groups.  When  the  areas  from  which  the  cells  have 
apparently  disappeared  are  examined  with  a  higher  power,  it  is  seen  that 
remnants  of  the  latter  are  still  present.  The  cells  are  surrounded  by  a  par- 
tially empty  cavity,  the  walls  of  which  are  covered  either  by  leucocytes  or 
nuclei,  while  the  cells  themselves  are  shrunk  to  a  very  variable  extent 
(fig.  5).  The  cell  membrane  appears  to  be  shrimk  aroimd  the  nucleus  and 
nucleolus,  along  with  a  small  quantity  of  granular  contents ;  but  one  or  more 
processes  can  almost  always  be  detected  ;  the  full-sized  cells  often  contain 
yellow  pigment  granules,  and  sometimes  appear  to  be  increased  instead  of 
diminished  in  size.  A  number  of  red  blood  corpuscles  are  infiltrated 
into  the  central  group  of  cells  (fig.  4,  c)  and  the  cells  themselves  are  much 
altered  and  diminished  in  size.  The  vesicular  colmnn  of  Clarke,  especially 
in  the  upper  dorsal  and  lower  cervical  regions,  is  usually  much  infiltrated 
with  leucocytes,  and  its  own  cells  are  often  deformed  and  shrunk.  At  the 
junction  of  the  dorsal  and  lumbar  regions,  the  cells  of  this  group  are 
frequently  found  healthy. 

§  935.  Morbid  Physiology. — The  mode  of  origin  of  hydro- 
phobia shows  that  the  disease  is  due  to  a  specific  animal  poison, 
and  the  anatomical  lesions  found  after  death  appear  to  indicate 
that  the  toxic  ag^nt,  whatever  its  nature,  is  conveyed  in  the 
blood  to  the  nervous  tissues.  There  is  nothing  specific  in  the 
miliary  abscesses  found  in  hydrophobia  as  they  are  observed 
in  other  diseases.  The  poison,  as  was  first  suggested  by 
Dr.  AUbutt,  appears  to  act  first  on  the  nuclei  of  the  medulla 
oblongata,  and  more  especially  on  the  respiratory  centres ;  then 
on  the  grey  matter  of  the  spinal  cord  ;  and,  lastly,  on  the  cortex 
of  the  cerebrum.  That  the  poison  of  hydrophobia  should  act 
in  this  manner  on  the  nervous  tissues  is  not  more  inscrutable 
than  that  the  poison  of  scarlet  fever  should  produce  an  erup- 
tion on  the  skin,  which  first  appears  on  the  chest,  then  extends 
to  the  forearms  and  lower  part  of  the  abdomen,  and  finally 
becomes  general. 

While  examining  the  spinal  cord  in  cases  of  hydrophobia 
I  was  much  struck  by  the  fact  that  the  cells  of  the  median 


I 


HYDROPHOBIA.  863 

group  and  the  marginal  cells  of  the  other  groups  of  ganglion 
cells  of  the  anterior  horns  were  invariably  altered,  while  the 
ganglion  cells  of  the  centres  of  the  groups  were  apparently 
unaffected.  It  was  in  my  power  to  take  refuge  in  the  supposi- 
tion of  a  special  affiaity  between  the  poison  and  these  cells, 
but  I  was  met  by  a  similar  vulnerability  of  the  same  cells  in 
tetanus,  in  all  central  inflammations  of  the  spinal  cord,  whether 
acute  or  chronic,  and  even  in  chorea.  It  was  in  this  state  of  doubt 
that  I  came  to  recognise  the  significance  of  two  other  facts  with 
regard  to  the  cells  in  question.  The  ganglion  cells  which  are  most 
vulnerable  in  all  affections  of  the  grey  substance  of  the  spinal 
cord  are,  speaking  broadly,  smaller  than  those  which  are  most 
resisting,  and  the  former  are  developed  at  a  much  later  period 
than  the  latter.  The  small  size  of  the  cells  enables  them  to 
present  a  large  surface  to  their  environment  in  comparison  with 
their  bulk,  and  consequently  they  must  absorb  a  proportionably 
larger  quantity  of  nourishment.  The  cell-membranes  of  the 
last  are  also  likely  to  be  thinner  than  those  of  the  first 
developed  cells,  and  this  will  increase  still  further  the  capacity 
of  the  former  for  the  absorption  of  nourishment.  The  ganglion 
cells  which  absorb  a  large  quantity  of  nourishment  in  a  rela- 
tively short  time  must  necessarily  suffer  at  an  earlier  period  in 
states  of  active  hypergemia  than  the  cells  which  absorb  a  less 
quantity,  while  they  will  be  equally  the  first  to  suffer  in  condi- 
tions of  anaemia,  inasmuch  as  the  want  of  nourishment  must  be 
first  felt  in  those  cells  which  are  undergoing  the  most  active 
changes.  There  are  no  grounds,  therefore,  for  believing  that 
the  accessory  manifest  a  greater  affinity  than  the  fundamental 
cells  for  the  virus  of  hydrophobia,  but  the  conditions  under 
which  nutrition  is  normally  carried  on  in  both  are  such  that 
the  former  suffer  in  this  disease  to  a  greater  degree  than  the 
latter. 

§  936.  Diagnosis. — The  history  of  a  bite  from  a  rabid  animal 
is  generally  sufficient  to  direct  attention  to  the  true  nature  of 
the  disease.  But  inasmuch  as  the  animal  is  generally  killed 
soon  after  inflicting  the  injury,  we  often  cannot  be  sure  that- it 
was  the  subject  of  rabies.  On  the  other  hand,  those  who  have 
been  bitten  by  dogs  or  other  animals  are  often  haunted  by  the 


864<  HYDROPHOBIA. 

dread  of  hydrophobia,  and  hysterical  symptoms  not  unlike  those 
of  the  actual  disease  may  become  developed  in  them.  In  cases 
of  the  kind,  besides  globus  hystericus,  other  symptoms  are 
generally  present  which  render  their  nature  apparent,  and, 
inasmuch  as  hydrophobia  is  almost  always  fatal  within  four 
days  from  the  commencement,  its  diagnosis  from  hysteria  cannot 
long  remain  matter  for  doubt.  It  must  also  be  remembered 
that  tetanus  may  occur  after  the  bite  of  an  animal  just  as 
after  other  injuries,  and  it  is  not  impossible  that  cases  of  reported 
recovery  from  hydrophobia  have  been  of  the  nature  of  tetanus. 
In  tetanus  the  patient  is  usually  calm  and  the  mental  faculties 
are  clear  to  the  last;  while  there  is  complete  absence  of 
the  emotional  excitement,  horror,  and  delirium  observed  in 
hydrophobia. 

§  937.  Treatment. — Every  effort  should  be  made  to  prevent 
the  development  of  the  disease.  The  tissues  surrounding  the 
wound  should  be  at  once  excised  with  the  knife,  or,  if  this  be  im- 
possible, destroyed  by  the  actual  cautery  or  powerful  caustics,  as 
potassa  fusa  or  nitric  acid.  Youatt  placed  the  greatest  reliance 
on  the  cauterisation  of  the  wound  with  the  solid  nitrate  of 
silver. 

When  the  disease  is  established,  every  effort  should  be 
directed  to  soothe  the  sufferings  of  the  patient.  In  the  cases 
coming  under  my  observation,  subcutaneous  injections  of 
morphia  and  chloral  appeared  to  be  productive  of  most  relief, 
inasmuch  as  several  hours  of  quiet  sleep  were  procured  for  the 
unfortunate  patient.  Hot-air  and  vapour  baths  have  been 
recommended,  and  the  latter  is  very  soothing  to  the  patient; 
but  there  are  no  grounds  for  believing  that  it  can  eliminate  the 
virus. 


865 


CHAPTER   IV. 


HYSTERIA. 

Hysteria  is  a  functional  disease  of  the  nervous  system  charac- 
terised by  paroxysms  of  convulsions  with  apparent  loss  of  con- 
sciousness, along  with  various  sensory,  motor,  vaso-motor,  and 
psychical  disturbances,  which  may  be  combined  in  such  mani- 
fold ways  that  the  grouping  of  the  symptoms  may  simulate  any 
one  of  the  numerous  organic  diseases  to  which  the  nervous 
system  is  liable. 

§  938.  Etiology. — Hereditary  predisposition  exerts  a  power- 
ful influence  in  the  production  of  hysteria.  The  transmission  of 
the  disease  is  sometimes  direct,  the  motlier  transmitting  it  to 
the  daughter,  and  at  other  times  indirect,  the  patient  inheriting 
a  neurotic  constitution  which  manifests  itself  in  one  member  of 
a  family  as  hysteria,  and  in  the  others  as  neuralgia,  epilepsy 
chorea,  or  insanity. 

Hysteria  occurs  with  preponderating  frequency,  although  by 
no  means  exclusively  in  the  female  sex.  Briquet  states  that 
one  out  of  four  of  all  females  are  affected  with  decided  hysteria, 
and  that  one-half  present  an  undue  impressionability  which 
differs  very  little  from  it,  a  proportion  much  too  high  for  this 
country.  Out  of  1,000  cases  collected  by  Briquet,  one  male 
was  affected  with  hysteria  in  proportion  to  twenty  females. 

The  disease  usually  begins  in  females  about  the  age  of 
puberty,  the  first  symptoms  being  manifested  in  more  than  half 
the  cases  collected  by  Briquet  between  twelve  and  twenty,  and 
in  a  third  of  them  between  fifteen  and  twenty  years  of  age. 
The  establishment  of  menstruation  does  not  appear  to  favour 

DDD 


866  HYSTERIA. 

the  development  of  hysteria,  although  the  affection  is  frequently 
associated  with  derangement  of  the  function. 

Hysteria  occurs  in  children  of  both  sexes  under  ten  years  of 
age.  Briquet  states  that  the  first  symptoms  appeared  in  children 
under  ten  years  in  about  one-eighth  of  his  cases,  a  proportion 
which  is  much  too  high  so  far  as  this  country  is  concerned. 
Boys  from  ten  to  fourteen  years  of  age  are  not  unfrequently  the 
■  subjects  of  hysteria ;  cases  of  the  kind  have  been  recorded  by 
Wilks  and  Roberts,  and  I  have  myself  seen  several  examples. 

All  causes  which  lower  the  nutrition  of  the  nervous  system, 
as  haemorrhages,  insufficient  nourishment,  impaired  digestion, 
and  aasemia,  predispose  to  hysteria. 

Hysteria  affects  the  females  of  the  higher  classes  of  society 
more  frequently  than  those  of  the  working  classes.  Young 
ladies  often  lead  an  utterly  aimless  existence,  periods  of  idle- 
ness alternating  with  the  unhealthy  excitement  afforded  by 
balls  and  theatres.  Under  such  circumstances  too  little  exer- 
cise is  apt  to  be  taken,  the  bowels  become  constipated,  digestion 
is  impaired,  and  angemia  results ;  all  of  these  are  conditions 
tending  to  diminish  the  nutrition  of  the  nervous  system.  The 
mental  energies  not  being  expended  on  any  healthy  occupation 
are  apt  to  be  directed  inwards  to  the  contemplation  of  the 
patient's  own  thoughts  and  feelings;  and  under  these  circum- 
stances the  emotions  connected  with  the  gratification  of  the 
sexual  impulses  are  apt  to  occupy  a  predominant  place  in  the 
thoughts.  This  mental  condition,  while  strengthening  the 
lower  emotions,  weakens  the  power  of  the  will,  and  induces 
that  excessive  irritability  of  the  nervous  system  which  under- 
lies hysteria. 

The  depressing  passions,  as  fear,  anxiety,  jealousy, and  remorse, 
frequently  induce  hysteria,  while  exhaustion  from  overwork 
when  combined  with  anxiety,  as  in  the  case  of  those  who  have 
to  nurse  sick  relatives,'  is  one  of  the  most  fruitful  causes  of  the 
disease. 

All  uterine  derangements,  whether  structural  or  functional, 
are  apt  to  be  attended  by  hysteria,  and  the  symptoms  are  liable 
to  become  aggravated  during  the  menstrual  periods  in  those 
who  are  already  hysterical.  The  name  hysteria  was,  indeed, 
given  to  the  disease  under  the  belief  that  it  was  always  caused 


HYSTERIA.  867 

by  disease  of  the  uterus  aod  its  appendages;  but  this  exclusive 
view  of  the  origin  of  the  disease  is  now  no  longer  maintained 
by  anyone.  Hysteria  may  be  acquired  by  those  who  are  pre- 
disposed to  it  by  the  imitation  of  others.  Young  susceptible 
girls  are  not  unfrequently  seized  with  hysteria  after  being 
witnesses  of  the  disease  in  another.  An  actual  epidemic  of 
hysteria  may  occur  in  public  institutions,  like  hospitals,  fac- 
tories, and  girls'  schools,  and  the  convulsive  epidemics  of  former 
ages  appeared  to  spread  in  this  manner. 

§  939.  Symptoms. — The  symptoms  of  hysteria  may  be 
divided  for  the  purpose  of  description  into :  (1),  those  which 
characterise  the  intervals  between  the  attacks ;  and  (2),  those 
which  constitute  the  hysterical  paroxysm. 

(1)  Inteeparoxysmal  Symptoms. 

(a)  Sensory  Disturbances. — Hyperesthesia  in  some  form  or 
another  is  seldom  absent  during  the  course  of  hysteria.  The 
acuteness  of  the  perceptive  faculties  is  sometimes  increased,  so 
that  hysterical  patients  may  see,  hear,  smell,  or  taste  objects 
imperceptible  to  the  healthy  ;  and  their  sense  of  touch  may 
also  be  preternaturally  acute.  But  disorder  of  the  common  or 
emotional  sensations  is  much  more  usually  met  with  than  dis- 
order of  the  special  or  intellectual.  Sensations  which  to  others 
are  indifferent  or  pleasant  produce  in  the  hysterical  the  highest 
degree  of  discomfort ;  and,  conversely,  sensations  disagreeable 
to  others  may  be  enjoyed  by  them.  Hysterical  patients  often 
complain  urgently  of  neuralgic  pains  in  various  parts  of  the 
body  in  the  absence  of  any  recognisable  cause. 

The  senses  of  touch  and  temperature  are  sometimes  increased 
in  acuteness.  Some  hysterical  patients  recognise  persons  and 
objects  by  the  sense  of  touch  with  an  accuracy  unknown  in  the 
healthy,  while  they  often  complain  of  pulsation  in  different  parts 
of  the  body,  which  can  only  be  explained  on  the  assumption  of 
an  increased  sensibility. 

Cutaneous  or  deep-seated  hyperalgesia  is  rarely  absent  in 
hysteria,  and  it  may  or  may  not  be  accompanied  by  spontaneous 
pains  in  the  affected  parts.     Cutaneous  hyperalgesia  is  some- 


868  HYSTERIA. 

times  widely  diffused,  so  that  the  slightest  movement  of  the 
patient  causes  discomfort.  In  most  cases,  however,  the  hyper- 
algesia is  limited  to  particular  portions  of  the  surface  or  to  one 
extremity,  a  circumscribed  portion  of  the  trunk,  or  half  the 
body,  while  irregularly  circumscribed  ansesthetic  patches  are 
sometimes  found  in  the  midst  of  a  hypersesthetic  region. 

The  neuralgiform  pains  which  occur  in  various  parts  of  the 
body  are  described  as  of  extreme  severity.  Neuralgia  of  the 
mammary  gland  is  sometimes  complained  of,  especially  at  the 
menstrual  periods;  while  a  fixed  and  severe  pain  in  the  left 
infra-mammary  region — probably  an  intercostal  neuralgia — is 
an  all  but  constant  symptom  of  hysteria.  The  skin  over  the 
mammae  may  become  so  sensitive  that  the  slightest  touch  or 
the  contact  of  the  dress  may  be  unbearable,  and  great  sensi- 
tiveness to  pain  is  often  observed  in  the  neighbourhood  of  the 
ensiform  cartilage ;  while  pains  of  a  dull,  heavy  character, 
accompanied  by  a  feeling  of  oppression  and  anxiety,  are  some- 
times experienced  at  different  parts  of  the  sternum. 

Severe  pain  diffused  over  the  whole  surface  of  the  abdomen 
is  a  not  uncommon  symptom  of  hysteria.  The  abdominal 
pain  is  usually  associated  with  tympanites,  and  the  sensitiveness 
to  touch  is  so  great  that  the  patient  cannot  bear  the  contact  of 
the  bed-clothes ;  while  deep  and  continuous  pressure,  on  the 
other  hand,  may  cause  little  or  no  discomfort,  especially  if 
the  attention  of  the  patient  be  diverted.  Hysterical  patients 
suffer  greatly  from  cardialgia,  and  when  it  is  associated,  as  is 
frequently  the  case,  with  persistent  vomiting  the  symptoms 
may  be  mistaken  for  those  of  perforating  ulcer  of  the  stomach. 
Many  hysterical  patients  suffer  from  a  great  craving  for  food, 
leading  them  to  eat  large  quantities ;  this  condition  is  probably 
caused  by  a  hypersesthetic  condition  of  the  mucous  membrane 
of  the  stomach.  Ovarian  hypersesthesia  (§  345)  is  sometimes 
observed,  and,  curiously,  this  condition  is  usually  associated 
not  with  hypersesthesia,  but  with  anaesthesia  of  the  same  side. 
Hysterical  patients  often  suffer,  especially  at  the  menstrual 
periods,  from  irritation  and  burning  at  the  labia  and  at  the 
vaginal  orifice,  these  sensations  being  not  unfrequently  asso- 
ciated with  increased  sexual  desire.  The  bladder  and  urethra 
are   also   excessively   sensitive    and    painful    in    such    cases. 


HYSTERIA.  869 

Hysteralgia  is  not  an  unfrequent  symptom  of  hysteria,  inde- 
pendently of  any  local  disease ;  coccygodynia  without  local 
disease  is  exceptional. 

Hysterical  patients  suffer  from  various  more  or  less  painful 
affections  of  the  back.  Cutaneous  hypersesthesia  is  sometimes 
present,  its  favourite  sites  being  circumscribed  portions  of  skin 
over  and  between  the  scapulae.  Tenderness  of  the  vertebra3  and 
surrounding  structures  is,  however,  a  more  frequent  symptom, 
the  sensitiveness  being  sometimes  limited  to  the  spinous  pro- 
cesses and  at  other  times  distributed  laterally  in  the  muscles  of 
the  vertebral  column ;  this  spinal  tenderness  is  frequently 
accompanied  by  genuine  neuralgia.  The  affection  already 
described  under  the  name  of  spinal  irritation  consists  of 
spinal  tenderness  in  association  with  other  aggravated  symptoms 
of  hysteria.  Increased  sensitiveness  of  the  muscular  afferent 
nerves  probably  cause  the  restlessness  frequently  experienced 
by  hysterical  patients. 

The  pains  and  hypersesthesia  frequently  occurring  in  and 
around  the  joints  are  deserving  of  particular  attention,  inasmuch 
as  they  are  often  mistaken  for  chronic  articular  disease.  Sir 
Benjamin  Brodie  was  the  first  to  direct  attention  to  the  fre- 
quency of  these  affections,  and  he  asserted  that  four-fifths  at 
least  of  the  joint  diseases  met  with  in  women  of  the  higher 
classes  of  society  are  purely  hysterical.  The  hip  and  knee 
joints  are  most  frequently  affected;  but  the  ankles,  wrists,  and 
even  finger  joints  may  be  attacked.  In  the  hysterical  affection 
pressure  upon  the  joint  produces  pain,  but  little  or  no  pain  is 
caused  by  forcible  apposition  of  the  articular  surfaces,  especially 
if  the  attention  of  the  patient  be  otherwise  engaged.  The 
disease  may  continue  for  years,  and  in  chronic  cases  the  joint 
may  become  slightly  swollen  from  oedema  of  the  surrounding 
soft  parts. 

The  senses  of  smell  and  taste  are  frequently  increased  in 
acuteness,  the  patients  recognising  tastes  and  odours  which  are 
inappreciable  to  most  people.  At  other  times  there  is  a  per- 
version of  these  senses,  and  the  patient  manifests  a  preference 
for  certain  tastes  and  odours  which  are  disagreeable  or  in- 
different to  others.  In  obedience  to  this  morbid  craving 
hysterical  patients  sometimes  devour  chalk,  cinders,  or  even 


870  HYSTERIA. 

disgusting  substances,  and  exhibit  a  liking  for  odours  like 
those  of  assafoetida  "and  valerian.  Hallucinations  also  of  taste 
and  smell  may  be  experienced  in  hysteria. 

The  sense  of  hearing  often  becomes  extremely  sensitive,  but 
intolerance  of  sound  is  more  frequently  met  with  than  true 
auditory  hypersesthesia.  Subjective  sensations,  such  as  ringing, 
blowing,  roaring,  are  sometimes  heard,  or  there  may  be  true 
auditory  hallucinations. 

The  sense  of  sight  is  sometimes  increased  in  acuteness,  but 
intolerance  of  light  is  more  frequent.  Under  the  latter  circum- 
stances the  patient  shuns  the  light,  and  the  power  of  detecting 
objects  in  the  dark  is  increased.  At  times  the  hypersesthesia 
only  exists  with  respect  to  a  particular  colour,  most  commonly 
red.  Sparks  and  jSashes  of  light  are  sometimes  complained  of, 
while  at  other  times  there  are  hallucinations  of  sight,  the  objects 
seen 'being  often  productive  of  disgust  and  horror. 

Anaesthesia. — Diminution  or  complete  loss  of  sensibility  is  a 
very  frequent  symptom  of  hysteria.  It  may  exist  over  a  large 
portion  of  the  surface  of  the  body,  and  may  implicate  the 
muscles  and  deeper  tissues  as  well  as  the  nerves  of  special  sense. 
Anaesthesia,  in  some  form  or  another,  occurs  frequently  after  a 
hysterical  attack,  and  the  more  severe  the  attack  the  more 
likely  is  anaesthesia  to  ensue ;  as  a  rule,  it  diminishes  in  the 
interval.  Sometimes,  however,  an  extensive  and  persistent 
anaesthesia  may  disappear  after  a  fresh  attack,  and  the 
sensibility  of  the  previously  affected  part  may  become  normal 
or  exaggerated,  or  the  anaesthesia  become  transferred  to  another 
portion  of  the  body. 

In  the  majority  of  cases  sensibility  to  pain  is  alone  altered, 
while  the  other  forms  of  cutaneous  sensibility  remain  normal. 
In  some  cases  tactile  sensibility  is  lost,  while  variations  of 
temperature  are  correctly  appreciated ;  in  other  cases  every 
form  of  cutaneous  sensibility,  as  well  as  that  of  the  muscles, 
bones,  and  joints,  is  abolished. 

Anaesthesia  of  the  mucous  membranes  is  not  of  uncommon 
occurrence  either  alone  or  in  connection  with  cutaneous  anaes- 
thesia. It  is  associated  with  diminution  or  loss  of  reflex  contrac- 
tility, neither  reflex  spasm,  lachrymation,  nor  reddening  being 
provoked  by  the  contact  of  foreign  bodies  with  the  affected 


HYSTERIA.  871 

conjunctiva,  nor  sneezing  by  the  inhalation  of  irritating  sub- 
stances when  the  nasal  mucous  membrane  is  implicated.  Sensa- 
tion may  be  abolished  in  the  mucous  membranes  of  the  pharynx, 
larynx,  and  respiratory  tract  generally,  and  the  occasional 
retention  of  urine  and  faeces  in  hysterical  patients  is  probably 
caused  by  ansesfchesia  of  the  mucous  membranes  of  the  bladder 
and  rectum,  inasmuch  as  in  such  cases  the  bladder  or  rectum 
may  sometimes  be  found  enormously  distended  without  having 
caused  more  than  a  trifling  amount  of  discomfort.  The  mucous 
membrane  of  the  genital  organs  and  of  the  urinary  passages 
is  sometimes  found  insensible.  The  mucous  membrane  of  the 
vulva  and  vagina  may  be  completely  anaesthetic.  This  con- 
dition is  found  in  highly  hysterical  married  women,  and  in  them 
there  is  an  entire  absence  of  sexual  desire  or  pleasure. 

The  special  senses  are  not  unfrequently  affected  by  anes- 
thesia in  hysteria,  more  especially  after  severe  hysterical 
seizure.  The  senses  of  taste  and  smell  may  be  lost,  the  loss 
being  sometimes  unilateral,  at  other  times  bilateral.  Deafness 
of  nervous  origin  is  also  occasionally  observed,  and  it  may  be 
limited  to  one  ear  or  affect  both. 

There  may  be  amblyopia  or  complete  amaurosis  of  one  or 
both  eyes,  unilateral  amblyopia  being  the  most  frequent 
condition.  Hysterical  amblyopia  consists  of  diminution  of  the 
acuteness  of  vision,  restriction  of  the  field  of  vision  and  achroma- 
topsia, while  sometimes  a  condition  simulating  hemiopia  may 
be  present.  An  ophthalmoscopic  examination  does  not  reveal 
any  changes  in  the  optic  discs. 

The  distribution  of  the  different  forms  of  hysterical  anaesthesia 
is  very  variable.  Cutaneous  8i,naesthesia  is  often  limited  to 
certain  circumscribed  portions  of  the  surface  of  the  trunk  and 
extremities ;  it  may  be  observed  in  the  region  of  distribution 
of  one  or  more  nerve  trunks,  be  limited  to  one  or  more  extremi- 
ties, or  be  accurately  confined  to  half  the  body. 

In  hysterical  hemiancesthesia  the  loss  of  feeling  on  the 
anaesthetic  side  frequently  affects  the  superficial  parts  only; 
but  at  other  times  the  muscles,  bones,  and  articulations  are 
implicated. 

Hemianalgesia  is  the  most  common  form  of  the  incomplete 
variety,  the  insensibility  to  pain  being  sometimes  associated 


872  HYSTERIA. 

with  thermo-angesthesia.  In  complete  hemiansesthesia  not  only 
the  skin,  but  the  muscles,  bones,  articulations,  and  the  special 
senses,  and  even  the  accessible  mucous  membranes  on  the 
same  side  of  the  body  are  implicated.  Taste  is  abolished  on 
the  corresponding  half  of  the  tongue,  the  sense  of  smell  is 
less  acute  in  the  corresponding  nostril,  and  partial  deafness  and 
amblyopia  exist  on  the  same  side.  The  anaesthesia,  however, 
does  not  appear  to  extend  to  the  viscera,  and  complete  hemi- 
ansesthesia is  usually  associated  with  ovarian  hyperesthesia. 

(b)  Motor  Disturbances. — Spasms,  either  tonic  or  clonic,  may 
occur  in  hysteria  in  every  muscle  or  group  of  muscles  of  the 
head,  trunk,  and  extremities.  Every  one  of  the  spasms  already 
described  as  occurring  in  the  area  of  distribution  of  one  or 
several  of  the  peripheral  motor  nerves  may  appear  in  hysteria 
in  the  form  of  a  more  or  less  persistent  or  of  recurring  contrac- 
tions. It  is  unnecessary  to  describe  them  in  detail.  The  facial 
muscles  are  incessantly  active  in  many  hysterical  patients,  so 
that  the  countenance  has  a  restless  and  unsettled  expression, 
constituting  one  of  the  main  characteristics  by  means  of  which 
the  practised  physician  is  enabled  to  diagnosticate  the  disease. 

Spasmodic  closure  of  the  glottis  may  produce  alarming 
dyspnoea,  and  the  patients  are  liable  to  attacks  of  convulsive 
laughter  and  weeping,  which  often  arise  apparently  in  the 
absence  of  any  emotional  disturbance.  During  hysterical 
attacks  loud  screams  are  commonly  emitted,  and  in  that  form 
of  hysteria  named  chorea  major  the  patients  often  imitate  the 
cries  of  animals  by  mewing,  barking,  or  howling.  Hysterical 
patients  often  suffer  from  a  temporary  acceleration  and  exag- 
geration of  breathing  without  there  being  any  feeling  of  embar- 
rassed respiration,  and  at  other  times  they  suffer  from  temporary 
spasmodic  pauses  in  the  respiratory  rhythm.  Hiccough  and 
yawning  are  frequent  and  sometimes  very  distressing  symptoms. 

The  pharyngeal  muscles  are  sometimes  spasmodically  con- 
tracted, so  that  swallowing  becomes  difficult  or  impossible. 
Spasm  of  the  tongue  is  not  unfrequently  associated  with  that 
of  the  pharyngeal  muscles.  At  every  attempt  to  move  the 
tongue  it  becomes  distorted  in  various  directions,  so  that 
articulation  and  swallowing  become  greatly  impeded.  The 
sensation  of  choking  in  the  throat,  named  globus  hystericus 


HYSTERIA.  873 

(§  61),  is  supposed  by  some  to  be  caused  by  a  spasm  of  the 
oesophagus.  The  sensation  of  a  foreign  body  in  the  throat  is 
sometimes  so  real  that  the  patient,  after  making  strenuous 
efforts  to  remove  it  by  swallowing,  puts  her  fingers  into  her 
throat  in  order  to  induce  vomiting,  by  which  she  hopes  to  eject 
it.  Actual  spasm  of  the  oesophagus  may  sometimes  be  so 
persistent  as  to  resemble  organic  stricture. 

The  stomach  is  liable  to  undergo  spasmodic  contractions, 
giving  rise  to  persistent  and  distressing  vomiting.  The  patient 
vomits  almost  immediately  after  food  is  taken,  so  that  the  latter 
is  usually  ejected  in  an  undigested  condition.  Some  of  the  food 
is,  however,  probably  retained,  as  the  nutrition  of  the  patient 
rarely  suffers  in  proportion  to  tbe  apparent  violence  and  per- 
sistency of  the  vomiting. 

Irregular  peristaltic  movements  occur  in  various  parts  of  the 
iijtestines,  and  these  may  be  so  energetic  that  they  can  be  felt 
through  the  abdominal  wall.  The  rolling  of  the  intestines  may 
convince  the  patient  that  a  movable  body  is  present  in  the 
abdomen.  Spasm  of  certain  portions  of  the  intestines  may 
be  so  persistent  as  to  cause  temporary  stricture,  and  the 
bowels  above  the  constricted  portion  become  greatly  distended 
with  gas,  giving  rise  to  what  has  been  called  a  "  phantom 
tumour;"  or  a  real  obstruction  of  the  bowels  may  sometimes 
be  caused  by  accumulation  of  faeces  behind  the  constricted 
portion.  Eructations,  borborygmi,  and  griping  pains  may  also 
be  caused  by  irregular  peristaltic  movements  of  various  portions 
of  the  digestive  canal. 

Spasmodic  retention  of  urine,  generally  combined  with  in- 
creased inclination  to  micturate,  occurs  in  many  hysterical 
patients;  and  this  condition  is  sometimes,  but  not  always, 
associated  with  a  painful  condition  of  the  genitals. 

Vaginismus,  caused  by  spasm  of  the  constrictor  vagina,  some- 
times renders  coitus  difficult  or  impossible ;  it  is  generally  asso- 
ciated with  hypersesthesia  of  the  vaginal  orifice,  the  spasm 
being  induced  by  reflex  action. 

Paralyses. — Partial  or  complete  loss  of  muscular  power  is  a 
frequent  symptom  of  hysteria.  Briquet  found  that  out  of  430 
cases  of  hysteria  120  suffered  from  paresis  or  paralysis ;  and 
Landouzy,  out  of  370  cases,  found  40  similarly  affected. 


874  HYSTERIA. 

The  loss  of  motor  power  may  begin  with  mere  weakness  and 
heaviness  of  the  limb  or  limbs,  which  gradually  increase  to 
complete  paralysis.  At  other  times  the  commencement  is 
sudden,  the  paralysis  becoming  fully  developed  after  a  hysterical 
attack. 

The  distribution  of  the  paralysis  is  very  variable.  It  may 
assume  the  hemiplegic  form,  and  in  these  cases  the  paralysis 
often  supervenes  after  an  attack  of  hysterical  convulsions, 
attended  with  partial  loss  of  consciousness,  which  may  last 
for  several  days,  so  that  the  hemiplegia  resembles  the  result 
of  organic  lesion  of  the  brain.  In  hysterical  hemiplegia  there 
is  no  distortion  of  the  face,  nor  deviation  of  the  tongue  on 
protrusion,  phenomena  which  are  almost  always  present  at 
first  in  hemiplegia,  due  to  cerebral  lesion.  In  hysterical  hemi- 
plegia the  paralysis  is  seldom  complete ;  in  the  majority  of 
cases  the  leg  is  more  profoundly  affected  than  the  arm,  and 
the  loss  of  motor  power  is  liable  to  considerable  variations  in 
intensity,  especially  under  the  influence  of  emotional  excite- 
ment. Hysterical  hemiplegia  is,  moreover,  generally  associated 
with  the  hemiancesthesia  already  described,  as  well  as  with 
ovarian  hypersesthesia,  retention  of  urine,  tympanites,  and  other 
symptoms  of  aggravated  hysteria.  Another  feature  worthy  of 
attention  is  that  the  convulsive  attack  which  preceded  the 
paralysis  is  always  produced  by  a  profound  moral  shock. 

One  extremity  only  is  affected,  or  the  upper  extremity  on 
one  side  and  the  lower  extremity  on  the  other,  and  total 
paralysis  of  all  the  extremities  is  not  unknown.  The  paralysis 
may  be  limited  to  one  or  more  motor  nerves,  or  to  one  of  the 
branches  of  a  nerve.  Hysterical  paralysis  of  the  ocular  muscles 
is  rare,  but  paralysis  of  one  or  both  the  levator  palpebrse 
superioris  muscles  is  not  unfrequent,  and  the  well-known 
hysterical  expression  is  probably  partly  due  to  the  drooping 
of  the  upper  eyelids,  caused  by  imperfect  contraction  of  these 
muscles. 

The  excitability  of  the  paralysed  muscles  to  both  the  faradic 
and  galvanic  currents  remains  unchanged  even  when  the 
paralysis  has  existed  for  years,  a  circumstance  of  great  im- 
portance in  establishing  a  correct  diagnosis.  After  long 
disuse  the  muscles  may  indeed  undergo  a  certain  amount  of 


HYSTERIA.  875 

atrophy,  in  which  case  there  may  be  a  slight  diminution  of 
electric  excitability,  but  the  "reaction  of  degeneration"  is  never 
established. 

Ansesthesia  is  frequently  associated  with  paralysis  in  hyste- 
rical patients,  although  each  of  these  conditions  may  be  present 
without  the  other.  When  both  conditions  are  combined  the 
anaesthesia  is  generally  not  confined  to  the  skin,  but  extends 
to  the  muscles,  and  then  "electro-muscular  sensibility"  is 
diminished  or  abolished.  Duchenne  regarded  this  condition 
as  a  very  valuable  sign  of  hysterical  paralysis,  but  it  must  be 
remembered  that  muscular  ansesthesia  is  sometimes  absent  in 
hysterical,  and  occasionally  present  in  paralysis  of  apoplectic 
origin.  Hysterical  paralysis  is  always  accompanied  by  other 
manifestations  of  the  disease,  such  as  spasm,  hypersesthesia, 
and  particularly  by  the  characteristic  psychical  condition. 

In  doubtful  cases  a  careful  observation  of  the  course  and 
progress  of  the  disease  will  aid  in  clearing  up  the  diagnosis. 
Hysterical  paralysis  is  generally  variable  in  its  duration,  con- 
tinuing for  a  few  hours,  days,  or  weeks,  and  then  completely 
disappearing,  perhaps  to  return  after  subsequent  attacks  of 
hysteria.  The  mode  of  extension  of  the  paralysis  is  sometimes 
characteristic.  It  may  be  pronounced  at  first  on  one-half  of 
the  body,  then  quickly  disappear  from  that  side  and  present 
itself  on  the  opposite  side,  or  it  may  be  crossed.  In  some 
cases  the  paralysis  continues  for  years  unchanged  in  extent ; 
in  these  cases  hysteria  may  be  difficult  to  distinguish  from 
hemiplegia  caused  by  circumscribed  lesion  of  the  brain,  or  from 
cerebro-spinal  sclerosis  and  spinal  paraplegia. 

Contracture  not  unfrequently  becomes  developed  in  the 
paralysed  extremities.  In  some  cases  the  contracture  appears 
simultaneously  with  the  paralysis,  while  in  other  cases  the 
paralysis  continues  for  some  time  and  then  contracture  super- 
venes gradually  or  suddenly  after  a  fresh  attack.  In  the 
upper  extremities  there  is  spasmodic  flexion  of  the  forearm, 
hand,  and  fingers  ;  the  muscles  are  in  a  state  of  considerable 
rigidity,  so  that  it  is  impossible  to  obtain  complete  extension, 
or  to  increase  the  flexion. 

The  lower  extremity  is  strongly  extended  upon  the  pelvis,  and 
the  leg  upon  the  thigh ;  the  foot  generally  assumes  the  position 


876  HYSTERIA. 

of  talipes  equino -varus ;  and  the  knees  are  drawn  inwards  by 
contraction  of  the  adductors  of  the  thighs. 

Contractures  may,  like  paralysis,  last  for  years,  and  then 
suddenly  cease,  generally  under  the  effect  of  strong  emotional 
disturbance.  In  other  cases,  when  the  contracture  has  continued 
for  many  years,  atrophy  of  the  affected  muscles  may  result, 
accompanied  by  the  "  reaction  of  degeneration."  Under  these 
circumstances  the  contracture  cannot  be  overcome  under  the 
deepest  chloroform  narcosis. 

In  hysterical  contracture  with  paralysis  tremor  is  sometimes 
observed,  especially  on  attempting  any  movement,  just  as  occurs 
in  the  paralysis  with  contracture  arising  from  sclerosis  of  the 
lateral  columns  of  the  cord. 

Charcot  relates  the  case  of  a  woman,  the  subject  of  hysteria, 
who  had  suffered  from  contracture  in  all  the  extremities  for 
ten  years.  The  degree  of  contracture  had  undergone  many 
fluctuations  for  several  years,  but  ultimately  became  perma- 
nently established,  and  a  post-mortem  examination  revealed 
sclerosis  of  both  lateral  columns  of  the  cord.  But,  as  Charcot 
remarks,  the  presence  of  tremors  in  cases  of  hysterical  contrac- 
ture, which  terminate  abruptly  in  recovery,  shows  that  this 
symptom  cannot  always  be  attributed  to  a  permanent  lesion  of 
the  lateral  columns. 

Tremor  may  also  occur  in  hysteria  independently  of  paralysis 
with  contracture,  and  it  then  closely  resembles  the  tremors  of 
paralysis  agitans  or  of  cerebro -spinal  multiple  sclerosis.  This 
tremor  may  appear  in  the  muscles  of  the  head,  tongue,  face,  or 
hands,  and  is  called  forth  and  aggravated  by  emotional  excite- 
ment. It  persists  during  repose,  if  the  patient  be  conscious  of 
being  observed. 

Hysterical  aphonia  from  paralysis  of  the  vocal  cords  is  a  very 
frequent  symptom  of  hysteria.  Aphonia  may  appear  suddenly 
after  some  mental  excitement,  and  disappear  with  equal  celerity. 
Difficulty  of  moving  the  tongue  is  sometimes  associated  with 
the  laryngeal  paralysis,  and  the  patients  no  longer  whisper, 
but  resort  to  pantomime  in  order  to  make  themselves  intelligible. 
Laryngoscopic  examination  shows  paralysis  of  the  adductors  of 
the  glottis  sometimes  on  one,  sometimes  on  both  sides. 

Paralysis  of  the  muscles  of  the  pharynx  and  the  oesophagus  is 


HYSTEKIA.  877 

not  an  uncommon  symptom  of  hysteria,  and  swallowing  may 
consequently  be  rendered  difficult  or  impossible.  In  such  a 
case  the  oesophageal  tube  passes  into  the  stomach  without  any 
obstruction.  Retention  of  urine  is  common,  and  often  paralytic 
in  origin. 

Paralysis  of  the  muscular  coat  of  the  stomach  is  partly  cause, 
partly  effect  of  the  general  tympanites  which  is  so  frequently 
met  with  in  hysterical  patients.  Tympanites  may  come  on 
suddenly,  in  consequence  of  mental  agitation  or  at  the  close  of 
a  hysterical  attack,  and  sometimes  reaches  such  a  degree  that 
the  patients  may  be  kept  afloat  in  a  bath  by  means  of  the 
gaseous  distention.  The  obstinate  constipation  which  is  so 
frequent  in  hysteria  is  probably  due  to  paralysis  of  the  muscular 
coat  of  the  bowels. 

(c)  Vaso-motor  and  Secretory  Disturbances. — In  the  inter- 
vals between  the  attacks  of  hysteria  the  action  of  the  heart 
and  the  pulse  may  be  normal,  unless  indeed  some  general 
disease,  like  chlorosis,  be  present.  Hysterical  patients  are, 
however,  liable  to  suffer  from  paroxysms  of  palpitation.  During 
these  attacks  the  pulse  is  at  first  frequent,  small,  and  hard ; 
the  skin  is  pale  and  cold ;  there  is  a  feeling  of  fulness  and 
oppression  in  the  chest;  and  there  may  be  a  degree  of  mental 
confusion.  After  a  time  the  cutaneous  vessels  relax  and  the 
surface  is  reddened  and  covered  with  perspiration ;  the  pulse 
then  becomes  slow,  full,  and  compressible.  Hysterical  patients 
are  liable  to  fainting  fits,  caused  doubtless  by  sudden  anaemia 
of  the  brain.  The  cerebral  anaemia  may  in  its  turn  be  produced 
either  by  vaso-motor  contraction  of  the  intracranial  arterioles, 
or  by  sudden  dilatation  of  the  arteries  of  the  body,  especially 
of  the  abdominal  arteries,  permitting  the  blood  to  accumulate 
in  the  dependent  parts. 

Various  other  alterations  of  the  vascular  tonus  may  occur 
in  hysteria,  independently  of  the  state  of  the  cardiac  action. 
Patients  frequently  complain  of  "  rushing  of  the  blood  to  the 
head"  and  flushing  of  the  face,  which  may  assume  an 
intensely  red  colour;  the  hands  and  feet  are  at  the  same  time 
pale  and  icy  cold,  and  the  mucous  membranes,  especially  of  the 
conjunctivae  and  lips,  are  anaemic.  Hysterical  subjects  are  liable 
to  become  pale  and  to  blush  alternately,  and  the  flushing  of  the 


878  HYSTERIA. 

face  is  often  accompanied  by  profuse  perspiration.  But  the 
alternate  contraction  and  dilatation  of  the  vessels  is  not  confined 
to  the  face.  In  hysterical  joint  affections  Brodie  observed  that 
coldness  and  pallor  of  the  affected  extremity  existed  for  some 
hours  daily,  to  be  succeeded  by  redness,  heat,  and  sweating  for 
a  similar  period,  the  latter  symptoms  in  their  turn  giving  place 
to  the  normal  condition.  The  hands,  which  are  dry  and  cold 
when  at  rest,  often  become  warm  and  moist  on  the  slightest 
attempt  at  manual  exercise,  such  as  writing,  and  even  the  cold 
hands  of  hysterical  patients  are  often  covered  by  a  clammy  sweat. 
The  whole  body  is  sometimes  prone  to  perspire,  while  uni- 
lateral sweating  is  occasionally  observed.  Neuralgic  affections, 
sometimes  accompanied  by  herpes,  are  frequently  associated 
with  local  hyperasmia  of  the  skin  in  hysterical  subjects. 

Charcot  has  drawn  attention  to  the  fact  that  in  the  complete 
form  of  hysterical  hemiansesthesia  the  anaesthetic  side  not  only 
suffers  from  comparative  pallor  and  coldness,  but  bleeds  little  or 
not  at  all  on  being  pricked  with  a  pin.  His  attention  was  first 
drawn  to  this  peculiarity  by  observing,  on  leeches  being  applied 
to  a  patient  affected  with  hysterical  hemianesthesia,  that 
their  bites  yielded  very  little  blood  on  the  anaesthetic  side ; 
while  the  healthy  side  bled  as  usual.  Charcot  believes  that 
hysterical  ischaemia  may  furnish  an  explanation  of  certain 
reputed  miraculous  occurrences,  as,  for  instance,  of  the  state- 
ment made  on  good  authority  that  in  the  epidemic  of  Saint 
Medard  the  sword  blows  given  to  the  " con vulsionn aires"  did 
not  cause  bleeding.  The  amenorrhoea,  so  frequently  associated 
with  hysteria,  is  probably  often  caused  by  local  ischaemia, 
although  it  sometimes  results  from  the  general  anaemia  which 
underlies  both  affections. 

Not  less  remarkable  than  hysterical  ischcemia  is  what  may 
be  termed  hysterical  hyperoimia.  Hysterical  hyperaemia  some- 
times leads  to  profuse  and  frequently  repeated  menstruation, 
although,  no  doubt,  both  the  menorrhagia  and  hysteria  some- 
times result  from  ovarian  disorder.  In  hysterical  ischaemic 
amenorrhoea  haemorrhages  may  take  place  from  other  organs, 
and  these  are  generally  regarded  as  vicarious  of  menstruation. 
The  mucous  membranes  of  the  nose,  throat,  stomach,  and  lungs 
are  the  favourite  sites  of  these  haemorrhages;  but  in  rare  cases 


HYSTERIA.  879 

they  occur  from  any  portion  of  the  surface  of  the  body,  and  in 
the  absence  of  any  recognisable  lesion  of  the  skia.  Hasmorrhages 
may  occur  in  the  hysterical  quite  independently  of  any  disorder 
of  the  menstrual  functions,  and  in  such  cases  they  are  due  to 
local  congestions  of  the  affected  organ. 

In  hysterical  hcematemesis  it  is  very  difficult  to  be  certain  of 
the  absence  of  gastric  ulcer,  since  the  presence  of  hysterical 
symptoms  does  not  exclude  the  co-existence  of  organic  disease. 
In  the  former  case,  however,  the  general  health  does  not  suffer 
in  proportion  to  the  apparent  gravity  of  the  symptom,  the 
patient  may  eat  indigestible  articles  of  diet  with  impunity, 
and  there  may  be  little  or  no  general  gastric  disturbance. 
Sometimes,  however,  the  diagnosis  can  be  made  only  after  pro- 
longed and  careful  observation.  The  same  remarks  apply  in 
great  measure  to  hysterical  haemoptysis.  Whenever  haemoptysis 
occurs  in  a  hysterical  patient,  the  most  careful  examination 
of  the  chest  should  be  made,  and  the  temperature  taken  night 
and  morning  for  some  days. 

In  the  examination  of  hysterical  patients  one  must  be  con- 
stantly on  the  alert  against  deception.  Such  patients  simulate 
haemoptysis  by  sucking  and  drawing  blood  from  their  gums, 
and  haematemesis  by  mixing  the  blood  of  animals  with  vomited 
matters,  or  even  by  drinking  the  blood  first  and  then  irritating 
the  fauces  so  as  to  induce  vomiting.  What  is  true  with 
regard  to  internal  haemorrhages  is  still  more  so  with  respect  to 
hsemorrhages  from  external  surfaces.  In  the  phenomenon  known 
as  stigmatisation,  large  bullae  form  on  various  portions  of  the 
surface,  especially  on  the  hands  and  feet,  chest,  and  forehead. 
These  bullae  are  at  first  filled  with  clear  serous  fluid,  which 
soon  becomes  of  a  bloody  colour,  and  then,  after  subsidence  of 
the  vesicle,  a  flow  of  blood  takes  place  from  the  surface  which  is 
tolerably  abundant  and  may  persist  for  a  long  time. 

There  are  well  authenticated  cases  of  haemorrhage  from  the 
surface  of  the  body.  Parrot  observed  an  escape  of  blood- 
coloured  fluid  from  the  skin  of  the  fingers,  knees,  thighs,  chest, 
and  conjunctiva  in  a  patient  at  different  times  during  general 
convulsive  attacks.  Laycock  mentions  a  case  in  which  there 
was  bleeding  from  the  nipple,  and  quotes  a  similar  case  from 
Sir  Astley  Cooper,   while   subcutaneous    extravasations   have 


880  HYSTERIA, 

been  frequently  observed  in  hysteria.  When  small  bleeding 
points  are  observed  on  the  surface  of  the  body,  suspicion  of 
deception  should  immediately  be  aroused.  Mention  has  already 
been  made  of  the  fact  that  in  hysterical  patients  ischsemia  fre- 
quently alternates  with  hypersemia,  and  if  during  the  former 
stage  several  pricks  were  made  with  a  pin  in  the  portion  of  skin 
affected,  these  would  not  bleed  at  first,  but  might  bleed  freely 
a  short  time  afterwards  when  the  hypersemic  stage  supervenes. 

Sudden  elevation  of  temperature  of  the  body  is  one  of  the 
most  remarkable  phenomena  of  hysteria.  In  the  case  of  a 
lady  who  suffered  from  anomalous  nervous  symptoms  after  a  fall 
from  a  horse,  under  the  care  of  Mr.  J.  Teale,  a  temperature  of 
122°F.  was  recorded.  More  or  less  similar  cases  have  been 
observed  by  Dr.  Donkio.  The  following  case,  reported  by  Dr. 
Steell,  is  a  good  example  : — 

M.  M ,  20  years  of  age,  a  nurse  in  the  Manchester  Koyal  Infirmary, 

first  came  under  medical  treatment  on  the  24th  of  October  last.  She  had 
been  out  nursing  a  case  of  erysipelas,  and  seemed  impressed  with  the  idea 
that  she  had  contracted  the  disease.  A  slight  blush  above  each  ankle  and 
a  transitory  and  shght  pyrexia  were,  however,  all  the  evidences  of  disease 
she  then  presented.  A  few  days  after  admission,  when  the  pseudo- 
erysipelas  had  entirely  subsided,  retention  of  urine  was  complained  of, 
and  it  was  learned  that  about  a  year  previously  she  had  been  similarly 
afiected,  but  had  not  come  under  medical  supervision.  The  urine  was 
drawn  ofi"  twice  daily,  and  various  remedies  were  employed,  without 
restoring  voluntary  micturition.  As  the  case  was  regarded  as  essentially 
hysterical  in  nature,  she  was  allowed  to  go  on  duty,  care  being  taken  that 
no  undue  distension  of  the  bladder  occurred.  Her  pulse  and  temperature 
at  this  time  were  always  found  to  be  normal.  Abdominal  pain  was 
occasionally  present,  and,  perhaps  wrongly,  was  attributed  to  distension 
of  the  bladder.  Menstruation  did  not  deviate  materially  from  the  normal. 
Other  remedies  having  failed,  faradisation  was  employed,  one  electrode 
being  attached  to  the  stilette  of  a  gum-elastic  catheter,  which  was  passed 
into  the  bladder,  a  sponge  electrode  being  applied  externally.  Acute 
cystitis  followed  this  application  on  one  occasion,  and  diu-ing  the  attack 
ample  evidence  was  given  that  the  power  of  voluntary  micturition  was 
entirely  wanting.  The  cystitis  passed  off'  in  a  few  days,  and  did  not  seem  to 
have  been  an  unmixed  evil,  some  return  of  voluntary  micturition  following 
Xt.  For  this  cystitis  she  had  been  again  warded  on  December  8th.  About 
this  time  Dr.  Thorburn,  obstetric  physician  to  the  Infirmary,  examined 
the  patient,  and  found  a  prolapsed  ovary  enlarged  and  very  tender.  She 
stated  that  she  had  frequently  pain  on  defecation,  and  abdominal  pain 
became  a  frequent  and  distressing  symptom.     This  was  chiefly  referred  to 


HYSTERIA. 


881 


the  left  iliac  region,  where  there  was  also  tenderness  on  pressure,  but  not 
limited  entirely  to  that  spot.  Her  temperature  at  this  time  became 
unsteady,  as  shown  by  the  following  observations :  December  8th,  evening, 
100-6°;  9th,  evening,  98-6°;  averaging  101°  from  the  11th  till  the  24th, 
when  it  reached  ■103*2''  in  the  morning.  This  temperature  was  not 
maintained,  and  the  thermometer  registered  100  "4°  on  the  evening  of  the 
25th.  The  temperature  remained  about  101°  (reaching  the  normal, 
however,  on  the  morning  of  the  28th)  till  the  30th,  when  the  remarkable 
abnormity  which  it  is  the  object  of  these  lines  to  record  began  to  manifest 
itself,  temperatures  of  105°  and  98"6°  (the  former  occumng  during  a  rigor) 
being  observed  the  same  evening.  The  temperature  after  this  continued 
irregular,  as  before,  tiU  the  3rd  of  January,  when  the  thermometer  in  the 
axilla  registered  106-6°  at  10  p.m.  during  a  rigor  (pulse  132).  On  the  8th, 
105-8°  was  noted  under  similar  circumstances,  but  shortly  after  99-4°. 
The  following  two  days  it  remained  normal,  and  on  the  1 1th  rose  only  to 
102-6°,  again  to  fall  to  normal.  I  regret  that  I  am  unable  to  furnish  an 
unbroken  curve  of  temperature  observations,  but  I  trust  the  facts  I  can 
substantiate  will  lose  none  of  their  value  on  that  account.  Eigors  now 
began  to  occm-  with  increasing  frequency,  each  being  accompanied  by  a 
rapid  and  great  rise  of  temperature.  They  were  irregular  in  occurrence, 
and  did  not  conform  to  any  definite  type.  Perspiration  usually  followed. 
It  will  be  seen  that  the  general  form  of  the  temperature  curve  would  most 
closely  resemble  that  of  pyaemia,  and  the  possible  existence  of  an  abscess 
in  or  about  the  ovary  could  not  but  suggest  itself.  The  general  condition  ■ 
of  the  patient  was  at  variance  with  this  hypothesis,  the  well-known 
features  of  intense  illness  being  absent.  I  shall  merely  mention  some 
single  observations  of  temperature,  giving  the  date  and  time.  It  may  be 
taken  for  granted  that  the  high  temperatures  were  those  observed  during 
or  immediately  after  a  rigor. 


January  24th,  11a.m.   ......  107-2° 

„         24th,  12  a.m 102-2° 

„        24th,  9p.m 101° 

„        25th,  evening  98-4° 

29th,        „         100-8° 

„         30th,  morning 97-8° 

„        30th,  evening  99-6° 

February  4th,        , 105° 

5th,        „         105-2° 

„  6th,  morning 99-8° 

10th,        „         105-4° 

16th,        „         99-4° 

„        16th,  evening  105-6° 

„        24th,  morning 98° 

„        24th,  5-35  p.m.    ...  108-6° 
„        24th,  10p.m.  (?)...  98-4° 

„        26th,  6p.m 112° 

„        28th,  4-30  p.m.    ...  113° 

March  1st,  morning  98-2° 

„       1st,  evening    100° 

EE  E 


March  3rd,  8-45  a.m 111° 

„  3rd,  10-30  a.m 108-2° 

„  3rd,  11-30  a.m 99-2° 

„  4th,  5-15  a.m 107-4° 

„  4th,  8-45  a.m 108° 

„  4th,  4p.m 112-4° 

„  5th,  8-50  a.m 108-6° 

„  5th,  2-30  p.m 106° 

„  5th,  3-45  p.m 107-4° 

„  7th,  10a.m 109° 

„  7th,  8-30  p.m 102-6° 

„  8th,  6  p.m 111-2° 

„  11th,  4-30  p.m 111-2° 

„  12th,  10  a.m 108° 

„  17th,  evening    100-4° 

„  18th,  3-30  p.m 116-4° 

■     „  19th,  4a.m 116°+ 

„  19th,  8  p.m 98-6° 

„  21st,    9-30  a.m 111°+ 

„  23rd,  9-30  a.m 106' 


882  HYSTERIA. 

During  the  last  few  weeks  of  treatment  mental  disturbance  has 
supervened.  At  first  this  accompanied  the  hyperpyrexia  only,  but 
latterly  it  has  been  nearly  constant.  She  has  no  fixed  delusion,  and  what 
delusions  she  has  manifested  have  been  clearly  founded  on  recent  events 
which  occurred  around  her.  They  tended  towards  the  melancholic  type 
of  insanity.  At  times  she  has  been  exceedingly  violent,  and  always  more 
or  less  suspicious.     There  is  no  family  history  of  insanity. 

I  believe  that  the  hyperpyrexial  attacks  were  of  very  short  duration, 
and  where,  by  the  above  figures,  a  prolonged  high  temperature  is  indicated, 
it  is  only  apparently  so,  the  observations  having  been  made  during  the 
rigors.  All  were  made  in  the  axilla,  and  different  thermometers  were 
used,  several  of  which  had  their  registering  columns  driven  into  the  bulb 
at  the  top  (indicated  above  by  the  symbol  +).  I  should  mention  that 
the  retention  of  urine  noted  at  the  commencement  has  continued,  with 
occasional  intermissions  of  varying  duration. 

These  lines  were  written  towards  the  end  of  March,  and  it  remains  for 
me  in  a  few  sentences  to  narrate  the  subsequent  history  of  the  case.  The 
attacks  of  hyperpyrexia  ceased  (though  transient  pyrexia  occurred  from 
time  to  time)  on  the  advent  of  a  new  series  of  phenomena,  including 
general  convulsions  of  extreme  violence,  accompanied  by  opisthotonos, 
loss  of  consciousness,  lividity,  &c.,  and  followed  by  persistent  trismus, 
simulating  in  a  remarkable  way  the  traumatic  form  of  that  affection. 
These  severe  symptoms  gradually  diminished  in  intensity  and  frequency 
while  general  amelioration  in  the  patient's  condition  set  in,  so  that  on  the 
12th  of  April  she  was  able  to  be  removed  to  the  Cheadle  Convalescent 
Hospital.  There  her  convalescence  continued  with  but  slight  interruptions, 
and  she  is  now  on  full  duty  as  a  nurse  in  the  institution. 

Hysterical  patients  suffer  from  various  anomalies  of  secretion 
and  excretion.  Increased  flow  of  saliva  is  not  an  unusual 
symptom  after  a  hysterical  attack,  and  it  occurs  occasionally 
independently  of  the  fits.  At  other  times  an  abnormal  dryness 
of  the  mouth,  along  with  great  thirst,  is  present,  inducing  the 
patients  to  drink  large  quantities  of  fluid. 

The  gastric  secretion  is  sometimes  largely  increased,  and  may 
take  place  independently  of  the  ingestion  of  food.  Hysterical 
vomiting  is  sometimes  caused  by  spasm  of  the  muscular  coat 
of  the  stomach,  but  at  other  times  it  appears  to  be  determined 
by  the  irritating  effect  of  the  excessive  gastric  secretion  upon 
the  mucous  membrane  of  the  organ,  while  in  many  cases  both 
conditions  are  probably  present  in  co-operation.  When  the 
vomiting  is  due  to  excessive  secretion,  large  quantities  of  fluid 
are  ejected,  even  during  fasting,  and  the  appetite  is  sometimes 
greatly  impaired,  and  at  other  times  enormously  increased. 


HYSTERIA.  883 

Hysterical  vomiting  is  not  often  accompanied  by  much  loss 
of  flesh,^  but  great  emaciation  may  take  place  in  hysteria  in 
the  absence  of  vomiting  or  any  recognisable  lesion  to  account 
for  it.  This  condition  has  been  described  by  Lasegue  under 
the  name  of  hysterical  anorexia,  and  by  Sir  W.  Gull  as  apepsia 
hysterica.  "  These  patients,"  says  Dr.  Wilks,  "  declare  that 
they  do  not  care  for  food,  and  so  they  take  less  and  less  until 
all  appetite  has  gone,  and  then,  indeed,  a  loathing  may  come 
on."  In  a  case  of  this  kind,  that  of  a  girl  aged  18  years,  which 
came  under  my  observation,  the  emaciation  was  extreme,  the 
skin  being  stretched  over  the  face  so  as  to  reveal  all  the 
depressions  and  prominences  of  the  jaws  and  malar  bones. 
The  condition  of  the  patient  reminded  me  forcibly  of  the 
appearance  presented  by  those  suffering  from  chronic  starvation, 
due  to  organic  stricture  of  the  oesophagus.  Some  months  subse- 
quent to  my  seeing  the  patient  her  parents  changed  their 
residence;  she  almost  immediately  began  to  eat,  and  became 
quite  plump  in  a  few  weeks. 

Hysterical  vomiting  is  sometimes  the  complement  of  hys- 
terical suppression  of  urine.  In  such  cases,  when  the  suppression 
of  urine  is  complete  and  of  long  continuance,  the  quantity 
vomited  is  large,  and  in  a  case  observed  by  Charcot  a  consider- 
able quantity  of  urea  was  detected  in  the  vomited  matters. 
Fernet  also  found  urea  in  the  vomited  matters  in  a  case  of 
this  kind.  It  is  therefore  probable  that  the  vomiting  is  caused 
by  the  supplemental  elimination  of  urea  by  the  stomach. 

The  renal  secretion  undergoes  frequent  alterations  in  hysteria 
Hysterical  polyuria  is  a  very  constant  symptom  after  convulsive 
attacks,  the  urine  under  such  circumstances  being  pale  and  of 
low  specific  gravity. 

Hysterica]  anuria,  although  seldom  met  with,  is  a  more 
interest! rig  phenomenon  than  polyuria.  Almost  total  suppres- 
sion of  urine  may  exist  for  a  period  of  weeks  or  months  without 
giving  rise  to  serious  symptoms  besides  the  constant  vomiting. 
Charcot  has  shown  that  this  curious  phenomenon  depends,  not 
upon  a  spasmodic  condition  of  the  ureter,  but  upon  some  dis- 
order of  the  kidneys  themselves,  probably  vaso-motor  contrac- 
tion of  the  renal  arteries  analogous  to  the  hysterical  ischsemia 
already  described  as  occurring  on  the  surface  of  the  body. 


884  HYSTERIA. 

Increase  of  the  vaginal  and  uterine  secretions  frequently 
occurs  in  hysterical  patients.  Leucorrhoea,  resulting  from  ute- 
rine disease,  may  sometimes  be  regarded  as  a  cause  of  hysteria, 
but  at  other  times  the  local  discharge  must  be  attributed  to 
nervous  influence. 

(d)  Psychical  Disturbances.  —  The  chief  mental  charac- 
teristic of  hysterical  patients  is  an  excessive  emotional  excita- 
bility, unchecked  by  voluntary  effort,  which  finds  expression 
in  various  ways.  Both  pleasant  and  unpleasant  emotions  are 
excited  in  them  with  unwonted  ease,  so  that,  as  Reynolds 
remarks,  "  the  patient  is  hurried  from  one  extreme  to  the  other 
with  ludicrous  rapidity  ;  and  often  she  walks,  as  it  were,  on  the 
narrow  line  where  tears  and  laughter  meet.  Laughter  and 
sobbing  not  only  alternate  but  co-exist,  and  often  without  any 
obvious  and  sufficient  reason  for  either."  This  excessive  emo- 
tional activity  necessarily  induces  exhaustion,  and  an  exhausted 
nervous  system  is  adapted  for  the  retention  of  the  painful 
emotions,  so  that,  as  a  rule,  hysterical  patients  are  irritable, 
gloomy,  and  not  only  exaggerate  bodily  ailments  which  exist, 
but  imagine  those  which  have  no  existence. 

Another  mental  peculiarity  of  hysterical  patients — a  pecu- 
liarity which  lies  at  the  root  of  almost  all  their  other  mental 
derangements — is  craving  for  sympathy.  Sympathy  is  the 
quality  of  mind  which  adapts  man  for  the  social  state,  and  is 
the  foundation  of  all  his  moral  actions ;  the  highest  natures 
must  necessarily  crave  for  the  sympathy  of  their  fellows ;  and 
the  more  highly  the  mind  is  developed  the  more  deeply  rooted 
will  the  craving  for  sympathy  probably  become.  Persons  with 
well-regulated  minds,  however,  perceive  that  those  have  no 
right  to  claim  the  regard,  esteem,  and  sympathy  of  others, 
who  refuse  to  be  sympathetic  in  their  turn  and  to  perform 
the  actions  which  are  prompted  by  an  active  sympathy  with 
the  feelings  and  sufferings  of  others.  They  are  constantly 
devising  schemes  by  which  they  can  alleviate  the  sufferings 
of  other  people,  and  thus  add  in  some  form  or  another  to  the 
stock  of  human  happiness ;  and  although  they  could  not  bear 
with  equanimity  to  be  regarded  with  dislike  by  their  fellows, 
especially  by  those  whom  they  esteem  good  and  wise,  yet  the 
desire  for  any  active  demonstration  of  sympathy  is  exceedingly 


HYSTERIA.  885 

small.  To  think  of  others  becomes  a  second  nature,  and  the 
true  method  by  which  to  purchase  the  inestimable  boon  of 
human  sympathy.  Sympathetic  natures  of  this  class  are  neces- 
sarily deeply  emotional,  but  the  life  of  active  benevolence 
which  they  lead  renders  it  necessary  for  them  to  develop  the 
intellect  in  adapting  means  to  ends  and  the  will  by  the  daily 
exercise  of  self-control.  Such  natures  are  emotional,  but  they 
are  also  strong-willed  and  of  vigorous  intellect ;  in  one  word, 
their  minds  are  well-balanced  and  healthy. 

Contrast  these  individuals  with  the  habitually  hysterical. 
Both  are  emotional,  and  both  crave  for  sympathy ;  but  while 
the  former  purchase  sympathy  by  actively  bestowing  it,  the 
latter  would  like  to  be  its  recipients  while  refusing  it  to  others. 
The  former  are  unselfish  and  devoted  to  the  interests  of  others, 
while  the  latter  are  selfish  and  regard  themselves  as  the  centre 
of  the  whole  world  of  feeling,  thought,  and  action. 

It  is  this  morbid  desire  for  sympathy  that  prompts  hysterical 
patients  either  to  exaggerate  a  real  ailment  or  to  feign  illness 
when  they  are  free  from  it,  or  even  to  inilict  bodily  injury  upon 
themselves  for  the  purpose  of  arousing  compassion  and  attention. 
Scarcely  a  disease  can  be  mentioned  which  may  not  be  simu- 
lated by  the  hysterical,  and  the  methods  they  adopt  to  effect 
their  object  are  truly  marvellous,  and  would  be  utterly  incredible 
unless  attested  upon  undeniable  evidence.  In  order  to  excite 
compassion,  some  injure  and  burn  themselves,  induce  purulent 
cutaneous  eruptions  by  the  use  of  irritating  ointments,  swallow 
needles,  or  even  pretend  that  they  are  about  to  commit  suicide, 
although  real  attempts  at  suicide  are  rare. 

The  depraved  ideas  formed  by  hysterical  patients,  and  the 
degrading  actions  resulting  from  them,  defy  all  description. 
Some  have  drunk  urine  and  eaten  excrement  in  order  they 
may  vomit  them  ;  others  have  led  their  too  credulous  attendants 
to  believe  that  arine  issued  from  their  navels,  breasts,  ears,  or 
eyes;  others,  again,  have  introduced  living  animals,  such  as 
frogs  and  worms,  into  the  anus  or  vagina,  so  that  they  might, 
by  reproducing  them,  excite  wonder,  and  become  objects  of 
sympathy  to  their  friends. 

But  there  are  lower  depths  of  human  degradation  which 
hysterical   females    do    not    fail    to   reach.     They    sometimes 


886  HYSTERIA. 

intrigue  against  their  friends,  and  maintain  that  they  are 
persecuted  and  outraged,  and  play  their  part  with  such  con- 
summate skill  as  to  deceive  experienced  physicians  and  learned 
judges.  Girls  about  the  age  of  puberty  sometimes  commit  the 
greatest  crimes  which  it  is  possible  to  imagine,  without  any 
recognisable  motive,  and  apparently  from  the  sheer  love  of  mis- 
chief. "  When  you  see  a  paragraph,"  says  Dr.  Wilks,  "  headed 
'  extraordinary  occurrence,'  and  you  read  how  every  night  loud 
rapping  is  heard  in  some  part  of  the  house,  or  how  the  rooms 
are  being  constantly  set  on  fire,  or  how  all  the  sheets  in  the 
house  are  being  devoured  by  rats,  you  may  be  quite  sure  there 
is  a  young  girl  on  the  premises." 

I  have  known  a  young  lady  at  a  boarding  school  tear  her 
sheets  and  her  own  underclothing  into  shreds,  and  then  endea- 
vour to  fasten  the  guilt  upon  a  schoolmate.  Another  placed 
a  carving-knife  under  her  pillow,  and  when  it  was  discovered, 
as  was  doubtless  intended,  she  confessed  to  an  intention  of 
committing  suicide. 

These,  however,  are  only  a  few  of  the  minor  vagaries  which 
may  be  committed  by  hysterical  girls.  A  young  nurse  girl  has 
not  unfrequently  been  known  to  poison  the  children  under  her 
charge,  at  other  times  the  attempt  is  directed  against  her 
mistress,  and  it  is  so  clumsily  carried  out  that  the  lives  of  the 
whole  family  may  be  endangered.  At  times  a  piece  of  burning 
coal  may  be  placed  under  the  infant  in  the  cradle,  and  repeated 
attempts  be  made  to  set  the  house  on  fire,  all  this  being  done 
while  the  girl  is  treated  with  the  utmost  consideration  and 
kindness  by  her  employers. 

The  well-known  case  of  Constance  Kent  testifies  to  the 
frightful  crimes  which  may  be  perpetrated  by  young  girls  in 
this  strange  condition.  Dr.  Wilks,  in  alluding  to  the  case, 
remarks :  "  When  a  few  years  ago  the  whole  country  was 
shocked  by  the  news  of  the  murder  of  a  little  boy  in  the  middle 
of  the  night  whilst  surrounded  by  members  of  his  own  family, 
the  event  was  enveloped  in  the  darkest  mystery,  seeing  that 
the  crime  was  of  so  extraordinary  a  character,  and  was  wanting 
in  all  those  objects  for  its  commission  which  are  usual  in  similar 
deeds.  No  adult,  especially  no  man  in  his  senses,  commits  a 
crime   except  to  attain  some  end ;    and,  therefore,  the  very 


HYSTERIA,  887 

purposelessness  of  the  act  (except,  perhaps,  for  revenge)  con- 
vinced me  that  it  was  perpetrated  by  a  young  woman.  I  felt 
quite  sure  in  my  own  mind  as  to  the  real  criminal,  who,  even 
after  her  own  confession,  was  considered  by  many  incapable  of 
such  a  deed." 

It  is  not  unusual  for  the  psychical  disturbance  of  hysteria  to 
assume  an  erotic  character.  Girls  may  then  assert  that  they 
have  been  ravished,  and  usually  maintain  that  the  most  out- 
rageous violence  was  used  by  the  perpetrator  of  the  crime,  or 
that  they  themselves  were  previously  drugged.  The  notes  of 
the  following  case  have  been  kindly  supplied  to  me  by  Mr. 
Cullingworth,  who  was  the  medical  witness  called  in  by  the 
police  to  investigate  the  case  after  her  supposed  dying  state- 
ment had  been  taken  : — 

lu  December,  1876,  a  girl  of  eighteen  was  found  one  evening  standing, 
with  her  clothing  wet  and  muddy,  and  in  an  apparently  stupefied  con- 
dition, in  the  closed  doorway  of  a  restaurant  in  the  centre  of  Manchester, 
a  few  yards  from  where  she  was  lodging.  She  was  taken  home  and  to 
bed,  and  a  medical  man  was  sent  for.  He  found  her  to  all  appearance 
unconscious  of  what  was  going  on  around  her,  and  uttering  some  dis- 
jointed and  incoherent  complaints  of  having  been  drugged  and  threatened. 
He  thought  she  was  recovering  from  the  effects  of  some  narcotic,  and  did 
not  at  first  pay  much  attention  to  her  story.  The  following  day,  however, 
she  appeared  worse,  and  in  the  evening  her  condition  was  considered  so 
critical  that  the  pohce  were  communicated  with,  with  a  view  to  her  state- 
ment being  taken  down.  She  was  visited  by  two  experienced  detectives, 
who,  seeing  how  matters  stood,  and  having  the  doctor's  assm-ance  that  she 
was  in  a  dying  state,  sent  at  once  for  a  magistrate,  before  whom  she  made 
a  solemn  declaration  to  the  following  effect:  She  behoved  herself' to  be 
dying.  On  the  previous  evening  a  sohcitor,  at  whose  office  she  had  called 
on  business,  told  her  that  she  must  go  into  a  convent,  and  gave  her  "some 
sort  of  dark,  sweet  drink,"  which  rendered  her  senseless.  On  going  down- 
stairs from  the  office  she  met  a  Jesuit  father,  whom  she  had  seen  once 
before.  This  gentleman  took  hold  of  her  and  pulled  her  along  the  street 
to  a  little  house  in  a  court,  where  there  was  an  upper  room  with  a  bed  in 
it  and  a  cross  on  the  wall.  Having  got  her  into  this  room,  he  said  im- 
proper things  to  her,  and  gave  her  a  little  cake  which  affected  her  directly. 
The  woman  of  the  house  came  into  the  room  and  found  her  on  the  floor, 
after  which  she  somehow  got  outside,  the  priest  following.  He  again 
dragged  her  along  in  the  dirt  to  the  street  corner,  when  he  ran  away. 

The  solicitor  and  the  priest,  both  of  them  well-known  and  highly- 
respected,  were  thereupon  placed  under  arrest  in  the  middle  of  the  night 


888  HYSTERIA. 

on  a  charge  of  having  administered  certain  poisonous  drugs  with  intent  to 
murder.  The  story  was  proved  to  be  purely  imaginary,  and  the  magistrates 
dismissed  the  case. 

It  is  not  only  the  actions  which  are  in  immediate  relation 
with  the  emotions  that  are  so  profoundly  disturbed  in  hysteria, 
but  grave  disorders  of  the  representative  feelings  and  cognitions 
occur.  Illusions  of  sight  are  common  in  the  early  stages  of 
severe  hysterical  attacks.  Charcot  has  drawn  attention  to  the 
fact  that  in  the  grave  cases  of  hysteria  associated  with  ovarian 
hypersesthesia  and  hemiansesthesia  the  patients  frequently  see 
rats  and  other  odious  animals  on  the  anaesthetic  side  of  the 
body,  or  with  the  eye  suffering  from  amblyopia.  At  other 
times  they  have  hallucinations  with  erroneous  ideas,  and 
some  of  the  images  that  have  appeared  during  the  paroxysm  are 
subsequently  considered  real.  The  entire  hysterical  paroxysm 
may  consist  of  a  succession  of  images  like  that  occurring  in 
vivid  dreams,  a  condition  generally  described  as  hysterical 
delirium. 

If  the  attacks  be  transient  and  occur  rarely,  the  patient  may 
recover  completely  from  their  effects  ;  but  if  they  recur  fre- 
quently, persistent  mental  aberration  is  after  a  time  established. 
The  delirium  frequently  makes  its  appearance  in  a  perfectly 
periodical  manner  and  without  any  recognisable  cause,  being 
regularly  preceded  by  a  condition  of  ill-humour  or  mental  irri- 
tability. In  other  cases  a  chronic  and  continuous  form  of 
mental  disturbance  is  established,  which  is  little  affected  by 
the  fits. 

One  variety  of  this  mental  condition  assumes  the  form  of  pure 
melancholy.  The  patients  are  anxious,  wretched,  and  incapable 
of  enjoying  the  society  of  others,  and  under  such  circumstances 
they  are  subject  to  uncontrollable  impulses  which  urge  them  to 
commit  outrageous  actions. 

A  second  form  of  chronic  continuous  hysterical  mental  dis- 
turbance corresponds  closely  to  the  clinical  description  of  the 
so-called  folie-raisonnante.  Patients  affected  in  this  way 
pursue  their  own  selfish  aims  with  the  greatest  perseverance, 
although  they  are  unfit  for  any  useful  employment;  the  sexual 
appetite  is  often  strongly  developed,  and  not  rarely  they  are 
given  to  drunkenness.     There  is  complete  absence  of  the  moral 


HYSTERIA.  889 

sense ;  they  are  quite  unable  to  curb  their  inclinations  and 
impulses ;  they  are  liars,  and  cheat  and  steal  with  the  greatest 
cunning  and  dexterity ;  and  are  always  ready  with  plausible 
reasons  to  cloak  the  perversity  of  their  actions,  while  they 
manifest  the  utmost  confidence  in  the  incontrovertible  nature  of 
their  arguments.  In  these  cases  the  intelligence  is  profoundly 
disturbed,  for  it  is  evident  that  the  statement  which  was  at  one 
time  a  conscious  fabrication  to  meet  an  emergency  is  afterwards 
reproduced  by  them  with  a  full  belief  in  its  truth.  They  fre- 
quently suffer  from  hallucinations,  which  may  gradually  become 
transformed  into  established  erroneous  ideas.  They  are  besides 
subject  to  occasional  outbursts  of  excitement,  which  after  a 
time  pass  into  pronounced  Qnaniacal  states. 

(2)  Hysterical  Attacks. 

Hysterical  fits  are  exceedingly  variable  in  the  combination  of 
their  symptoms  and  the  degree  of  their  intensity,  so  that  it  is 
impossible  to  comprise  all  the  various  forms  under  one  general 
description.  The  attacks  occur  sometimes  without  any  recog- 
nisable cause,  while  at  other  times  they  are  provoked  by 
over-excitement  or  some  slight  emotional  disturbance.  The 
paroxysm  always  takes  place  when  someone  is  present  to  witness 
it,  and  never  during  sleep,  nor  when  the  patient  is  alone. 

(a)  Simple  Hysterical  Attack. — The  attack  is  preceded  by 
the  sensation  of  globus  along  with  a  feeling  of  suffocation,  a 
painful  dragging  in  the  extremities,  pain  and  giddiness  in  the 
head,  singing  in  the  ears,  or  darkening  of  the  field  of  vision. 
It  is  often  preceded  by  a  fit  of  crying  or  laughing,  or  a 
combination  of  both;  the  patient  suddenly  screams  or  makes 
a  spluttering  noise,  and  falls  down  in  a  state  of  apparent 
unconsciousness.  The  head  and  extremities  become  affected 
with  general  rhythmical  clonic  convulsions,  the  breathing  is 
accelerated  and  exaggerated,  irregular,  or  temporarily  arrested. 
The  loss  of  consciousness  is  more  apparent  than  real.  The 
hysterical  patient  generally  hears  what  is  said  by  those  around 
her,  and  she  has  almost  always  time  to  find  a  suitable  place 
upon  which  to  fall ;  she  often  throws  herself  on  a  couch  or 
reclines  on  a  sofa,  and  not  unfrequently  appears  to  bestow  some 
degree  of  attention  upon  the  propriety  and  gracefulness  of  her 
attitude. 


890  HYSTERIA. 

Another  peculiarity  of  the  hysteric  attack  is  that  the  facial 
expressions  and  attitudes  assumed  are  not  devoid  of  meaning, 
but  are  repetitions  of  those  occurring  in  health  under  varying 
emotions.  Sometimes  the  expression  is  that  of  great  terror,  at 
other  times  there  is  a  frown  as  if  of  anger,  and  at  still  other 
times  it  becomes  imploring  or  beseeching. 

Hysterical  attacks  rarely  last  more  than  a  few  minutes,  but 
they  may  recur  in  quick  succession,  so  that  they  seem  to  form 
an  almost  continuous  paroxysm,  extending  over  a  considerable 
period.  The  hysterical  seizure  frequently  ends  in  a  fit  of  crying 
and  sobbing,  there  is  no  subsequent  coma,  and  on  recovery  the 
patient  generally  passes  a  large  quantity  of  clear  and  limpid 
urine  of  low  specific  gravity. 

(6)  Cataleptic  attacks  are  liable  to  occur  in  hysterical 
patients;  they  are  of  variable  duration,  disappearing  some- 
times in  the  course  of  a  few  hours,  and  being  prolonged  at 
other  times,  with  slight  intermissions,  for  a  period  of  months. 
Cataleptic  rigidity  is  sometimes  limited  to  particular  limbs; 
but,  as  a  rule,  the  whole  body  is  implicated,  and  then  all 
voluntary  movements  are  suspended  and  reflex  action  is  dimi- 
nished. All  the  forms  of  general  sensibility  are  usually  lost,  but 
one  or  more  of  the  special  senses  may  be  retained.  The  sense 
of  hearing  is  probably  the  one  most  generally  retained,  a  fact 
which  should  be  borne  in  mind  by  the  attendants. 

Sometimes  every  form  of  sensibility  appears  to  be  completely 
abolished,  and  in  such  cases  the  limbs  retain  the  position  in 
which  they  are  placed.  This  condition  has  been  called  waxy 
rigidity,  because  the  limbs  can  be  as  it  were  moulded  in  almost 
any  position. 

There  are  cases  of  complete  general  muscular  relaxation  in 
which  the  action  of  the  heart  and  pulse  become  almost  imper- 
ceptible, while  respiration  may  be  so  feeble  that  the  patient 
may  seem  to  be  dead.  These  cases  have  been  described  as 
"  hysterical  trance,"  and  it  is  possible  that  patients  may  have 
been  buried  alive  in  this  condition. 

(c)  Hysteria  in  Boys. — Boys,  at  the  approach  of  puberty,  not 
unfrequently  suffer  from  hysterical  symptoms  resembling  those 
observed  in  the  female  sex  (Wilks,  Roberts).  Sometimes  the 
symptoms  may  assume  the  form  of  globus  along  with  attacks  of 


HYSTERIA.  891 

causeless  weeping  and  sobbing ;  at  other  times  there  may  be 
partial  spasm  of  the  glottis,  a  barking  cough,  attacks  of  dyspnoea, 
or  some  local  sensory  or  motor  disturbance.  Psychical  pheno- 
mena often  predominate.  In  a  case  which  I  saw  a  few  months 
ago  the  boy  was  sometimes  found  creeping  on  his  hands  and 
knees  and  barking  like  a  dog  ;  another  time  he  jumped  like  a 
frog  from  the  floor  on  to  the  table.  The  depraved  form  of 
hysteria,  named  chorea  'major,  is  often  met  with  in  boys.  In 
this  variety  of  the  disease  the  patients  run,  dance,  jump,  or 
climb  with  much  greater  readiness  and  dexterity  than  similar 
actions  could  be  performed  in  health,  or  they  may  sing  or  recite 
poetry,  even  in  a  foreign  language. 

The  paroxysm  of  hystero- epilepsy  will  be  subsequently 
described. 

§  940.  Course,  Progress,  and  Terminations. — The  grouping 
of  the  symptoms  in  hysteria  is  exceedingly  variable,  not  only 
in  the  case  of  different  individuals,  but  of  the  same  individual 
at  different  times.  It  is  almost  always  a  chronic  disease,  which 
exists  for  years,  and  disappears  only  at  an  advanced  age.  Those 
who  are  strongly  predisposed  to  hysteria  are  frequently  very 
irritable  and  peevish  during  childhood,  although  convulsive 
attacks  do  not  generally  occur  until  the  period  of  puberty. 
When  puberty  is  established  the  convulsive  attacks  frequently 
disappear,  and  other  symptoms,  more  especially  emotional  dis- 
turbances, are  then  apt  to  become  prominent. 

In  some  hysterical  patients  sensory  and  motor  disturbances 
are  well  marked  and  persistent,  and  psychical  only  present  to 
a  slight  extent,  while  at  other  times  the  reverse  is  the  case. 
The  disease  is  liable  to  undergo  many  variations  in  its  course. 
The  symptoms  may  disappear  for  comparatively  long  periods, 
but  are  liable  to  recur  on  exposure  to  the  slightest  excitement. 

Hysterical  symptoms  frequently  cease  after  the  climacteric 
period,  but  the  higher  degrees  of  mental  disturbance  sometimes 
develop  at  this  age. 

Hysterical  symptoms  may  appear  at  puberty,  but  subse- 
quently become  latent  to  a  certain  extent,  reappearing  in  a 
very  pronounced  manner  at  the  climacteric  period.  Hysterical 
symptoms  may  be  of  every  degree  of  intensity  from  simple 


892  HYSTERIA. 

mental  irritability  up  to  the  profound  mental  disorders  which 
border  upon  insanity,  and  from  slight  sensations  of  globus  and 
infra-mammary  neuralgia  to  attacks  of  general  convulsions, 
and  widely  spread  paralysis  and  anaesthesia.  The  cases  in  which 
convulsions,  paralysis,  anaesthesia,  and  contractions  are  associated 
with  severe  psychical  disorders  constitute  the  most  aggravated 
forms  of  the  disease. 

Hysteria  seldom  shortens  life.  Even  cases  of  persistent 
vomiting  and  copious  haemorrhage  are  relatively  innocuous  in 
comparison  with  similar  symptoms  arising  from  other  diseases. 
Cases,  however,  are  occasionally  observed  in  which  after  a  severe 
moral  shock  violent  hysterical  symptoms  become  developed,  and 
death  may  occur  within  a  few  days  or  weeks  in  the  absence  of 
any  recognisable  organic  change. 

In  a  case  of  hystero-epilepsy  observed  by  Wunderlich,  the 
patient  suffered  from  epileptiform  attacks,  not  attended  by  any 
increase  of  temperature,  for  more  than  eight  weeks,  when  sud- 
denly, without  known  cause,  the  patient  became  collapsed,  and 
the  temperature  rose  to  109  4°  F.  (43°  C.)  before  death.  In 
a  second  case,  related  by  the  same  author,  the  patient  suffered 
for  several  years  from  various  forms  of  paralysis,  hyperaesthesia, 
loss  of  sight  and  smell ;  ultimately  difficulty  of  swallowing  and 
vomiting  supervened,  and  she  died  with  febrile  symptoms  in  a 
state  of  marasmus  and  emaciation,  while  post-mortem  examina- 
tion revealed  no  changes  in  the  nervous  system. 

Sometimes  death  may  occur  indirectly  from  hysteria,  as  in 
the  cases  of  patients  who  mutilate  themselves,  with  or  without 
the  intention  of  committing  suicide.  Hysterical  patients  rarely 
attempt  to  commit  suicide  in  earnest,  but  feigned  attempts  made 
in  order  to  attract  attention  have  sometimes  been  fatal,  and 
occasionally  suicide  has  actually  been  committed. 

§  941.  Morbid  Anatomy  and  Physiology. — No  constant 
anatomical  changes  have  been  found  in  cases  that  have  died 
from  hysteria.  Charcot  discovered  symmetrical  sclerosis  of  the 
lateral  columns  extending  nearly  the  whole  length  of  the  spinal 
cord  in  the  case  of  a  hysterical  woman  who  suffered,  for  ten 
years,  from  paralysis  with  contracture  of  all  the  extremities. 
It  is,  therefore,  probable  that  in  cases  of  hysterical  contracture 


HYSTERIA.  893 

the  fibres  of  the  pyramidal  tracts  undergo  morbid  changes, 
at  first  temporary,  although  ultimately  becoming  permanent. 
But  even  if  this  be  so,  the  primary  change  probably  occurs  in 
the  motor  centres  of  the  cortex  of  the  cerebrum.  Indeed  all 
the  phenomena  of  hysteria  may  be  explained  most  readily  on 
the  assumption  that  the  irritability  of  the  cortex  of  the  brain 
is  sometimes  in  excess  and  sometimes  diminished  or  abolished. 
Increased  irritability  of  the  cells  and  fibres  of  portions  or  the 
whole  of  the  cortex  of  the  cerebral  hemisphere  supplied  by  the 
posterior  cerebral  artery  would  account  for  the  hypersesthesia  of 
variable  distribution  and  completeness  on  the  opposite  side  of 
the  body ;  and,  conversely,  diminution  or  loss  of  the  irritability 
of  those  same  cells  and  fibres  would  account  for  the  various 
forms  of  ansesthesia. 

Again  increased  irritability  of  the  cells  and  fibres  of  portions 
of  the  cortex  of  one  hemisphere  supplied  by  the  middle  cere- 
bral artery  would  account  for  spasms  of  groups  of  muscles  on 
the  opposite  side  of  the  body,  while  diminution  or  loss  of  the 
irritability  of  these  cells  and  fibres  would  account  for  the 
various  forms  of  paralysis  observed.  Variations  in  the  degree 
of  irritability  of  the  cells  and  fibres  of  the  cortex  supplied  by 
the  anterior  cerebral  artery  would  account  for  many  of  the 
psychical  disturbances.  Even  the  numerous  vaso-motor  disorders 
observed  in  the  course, of  hysteria  are  best  explained  on  the 
supposition  that  they  are  determined  by  variations  in  the 
intensity  of  the  nervous  discharges  from  the  cortex  of  the  brain 
to  the  nerve  centres  in  the  medulla  oblongata. 

HemianaBsthesia  from  organic  lesion  is  generally  caused  by 
disease  of  the  sensory  peduncular  fibres  and  of  Gratiolet's  fibres 
in  their  ascent  through  the  internal  capsule  ;  and  hysterical 
hemiansesthesia  might  result  from  a  loss  of  the  irritability  of 
these  fibres  without  recognisable  structural  change,  while 
hypersesthesia  of  half  the  body  might  be  caused  by  excessive 
irritability  of  them.  Muscular  spasm  or  paralysis,  on  the  other 
hand,  might  be  caused  respectively  by  excess  or  abolition  of  the 
irritability  of  the  fibres  of  the  pyramidal  tract.  The  fact  that 
ansesthesia  is  sometimes  associated  with  loss  of  reflex  irrita- 
bility shows  that  the  irritability  of  the  nervous  tissues  is  modi- 
fied in  hysteria  in  more  than  one  locality  at  the  same  time. 


894  HYSTERIA. 

§  942.  Diagnosis. — When  hysteria  is  fully  developed,  and 
the  physician  has  an  opportunity  of  inquiring  into  the  history 
of  the  case  and  of  watching  its  progress,  the  diagnosis  presents 
no  great  difficulties.  Hysteria  may,  however,  simulate  almost 
every  possible  disease,  and  a  physician  has  to  be  constantly 
on  his  guard  if  he  would  not  at  some  time  fall  a  victim  to  the 
deceptions  practised  by  the  hysterical. 

Individuals  of  a  nervous  temperament  sometimes  exhibit 
the  minor  characteristics  of  hysteria,  such  as  great  irritability 
of  temper,  exaggerated  sensibility  to  physical  impressions,  and 
even  occasionally  slight  motor  disorders.  Cases  of  this  kind 
bordering  upon  hysteria  demand  the  same  treatment,  so  that 
it  is  unnecessary  to  enter  upon  the  diagnosis  between  the 
affections. 

Hysterical  arthritic  affectious  are  particularly  liable  to  be 
mistaken  for  organic  disease  of  the  joints.  In  the  hysterical 
affection  the  pain  varies  in  degree  at  different  times  and  is 
fluctuating  in  character,  the  form  of  the  joint  is  unchanged, 
there  is  no  heat  or  redness,  and  the  pain,  like  most  other 
local  hysterical  pains,  is  limited  to  the  surface,  so  that  slight 
contact  may  be  painful  while  deep  pressure  causes  no  dis- 
comfort, especially  if  the  attention  of  the  patient  be  otherwise 
engaged. 

Pain  and  sensitiveness  over  the  spinous  processes  of  the 
vertebrae  in  hysterical  subjects  have  led  to  the  affection  being 
mistaken  for  grave  organic  disease  of  the  spinal  cord,  but  these 
symptoms,  indeed,  are  rarely  present  in  the  organic  diseases. 
The  exciting  causes  of  hysteria  simulating  disease  of  the  cord 
are  usually  emotional  disturbances,  which  rarely  induce  organic 
spinal  affections. 

In  hysterical  paraplegia  the  lower  extremities  are  feeble 
and  give  way  under  the  weight  of  the  body,  while  the  feet  drag 
on  the  ground.  The  paralysis  is  seldom  complete,  the  patient 
is  able  to  move  her  limbs  in  bed  with  comparative  ease,  and 
may  even  be  able  to  get  out  of  bed  ;  but  after  walking  two  or 
three  steps  the  limbs  give  way,  the  gait  becomes  tottering,  and 
unless  supported  the  patient  falls.  The  electric  excitability  of 
the  muscles  is  usually  unaffected  in  hysteria,  and  the  muscles 
do  not  undergo  trophic  changes. 


HYSTERIA.  895 

The  concomitant  symptoms  of  hysterical  paraplegia  are 
ansesthesia  of  the  skin  and  muscles  of  the  lower  extremities, 
tympanites,  constipation,  dysmenorrhoea,  and  retention  of  urine. 
Cerebro-spinal  multiple  sclerosis  sometimes  closely  resembles 
hysteria,  and  the  diagnosis  between  the  two  affections  is  occa- 
sionally only  practicable  in  the  later  stages. 

Hysterical  hemiplegia  differs  from  hemiplegia  due  to  cerebral 
disease,  in  the  following  respects : — It  is  usually  accompanied 
by  well-marked  disorders  of  sensibility ;  there  is  no  facial  or 
lingual  paralysis  ;  the  paralysis  is  scarcely  ever  complete ;  in 
the  large  majority  of  cases  it  is  worse  in  the  leg  than  the  arm ; 
it  is  liable  to  sudden  variations  in  intensity  under  the  influence 
of  emotions  ;  the  electric  excitability  is  unchanged  ;  and  the 
muscles  do  not  undergo  atrophy. 

Hysterical  convulsions  may  be  distinguished  from  epilepsy 
by  negative  characters.  The  loss  of  consciousness  in  the  former 
is  not  complete,  nor  is  it  so  sudden  in  its  onset ;  there  is  no 
asphyxia ;  the  tongue  is  not  bitten ;  the  attacks  last  longer 
than  in  epilepsy  ;  the  patient  does  not  on  the  cessation  of  the 
attack  fall  into  a  profound  stupor,  but  only  appears  exhausted  ; 
and  there  is  much  sobbing  and  crying. 

It  is  sometimes  difficult  to  distinguish  between  hysteria  and 
hypochondriasis.  Some,  indeed,  regard  hysteria  in  the  female, 
and  hypochondriasis  in  the  male,  as  only  different  manifesta- 
tions of  the  same  disease.  The  psychical  symptoms  of  the  two 
diseases  are,  however,  different,  and  paralyses  and  convulsive 
attacks  never  occur  in  hypochondriasis. 

Hysterical  aphonia  is  seldom  accompanied  by  a  cough  as  is 
laryngitis,  the  loss  of  voice  is  sudden,  while  in  almost  all  other 
forms  of  aphonia  the  voice  becomes  gradually  extinct ;  a  laryngo- 
scopic  examination  shows  a  total  absence  of  any  structural 
lesion. 

Hysterical  neuralgia  has  not  the  intensity  of  the  genuine 
disease,  and  there  is  an  absence  of  "  painful  spots."  The  dis- 
tribution of  pains  in  hysteria  is  more  diffused  than  in  true 
neuralgia,  and  often  not  limited  to  any  one  nerve  territory. 

In  lead  paralysis  the  affected  muscles  undergo  atrophy  and 
manifest  the  reaction  of  degeneration  at  an  early  period  of  the 
disease,  phenomena  which  never  appear  in  hysterical  paralysis. 


896  HYSTERIA, 

§  943.  Prognosis. — So  far  as  life  is  concerned,  the  prognosis 
is  always  favourable ;  it  should  not  be  forgotten,  however,  that 
a  fatal  issue  is  possible. 

But  although  hysteria  rarely  causes  death,  it  is  almost  equally 
rare  for  complete  recovery  to  take  place.  The  most  hopeless 
cases  are  those  in  which  a  predisposition  to  the  disease  is  in- 
herited, and  in  which  the  symptoms  commence  in  childhood. 
In  such  cases  the  disease  usually  becomes  exaggerated  at 
puberty,  although  considerable  remissions  often  take  place  after 
this  period.  Many  patients  get  well  as  age  advances,  and  at 
times  the  climacteric  produces  a  favourable  change  ;  but  at 
other  times  this  period  induces  exacerbations,  and  leads  to  the 
establishment  of  inveterate  forms  of  mental  disturbance. 

The  most  favourable  cases  are  those  in  which  the  disease 
can  be  traced  to  a  distinct  exciting  cause  that  can  be  removed, 
rather  than  to  rooted  mental  predisposition.  When  hysteria 
has  been  induced  by  affections  of  the  generative  organs  or 
chlorosis,  hopes  may  be  entertained  that  the  hysterical  symp- 
toms will  vanish  with  the  removal  of  these.  Occasionally, 
however,  the  altered  condition  of  the  nervous  system  continues 
after  the  exciting  cause  is  removed. 

Remissions  frequently  occur  in  the  course  of  the  disease,  and 
may  last  for  years,  but  the  symptoms  generally  recur  from  time 
to  time  in  one  form  or  another. 

Sensory  and  motor  disturbances,  however  severe,  may  sud- 
denly disappear  temporarily ;  but  the  symptoms  become  more 
obstinate  to  treatment  every  time  they  are  repeated,  and 
ultimately  become  persistent. 

Transitory  psychical  disturbances,  even  when  they  are  very 
violent,  may  not  exert  an  unfavourable  influence  upon  the 
progress  of  the  case ;  and  even  attacks  of  ordinary  insanity 
supervening  in  the  course  of  hysteria  are  capable  of  complete 
recovery.  When  once  the  mental  disturbance  has  assumed  a 
chronic  form  the  prognosis  becomes  extremely  unfavourable, 
and  when  the  signs  of  moral  depravity,  folie-raisonnante,  or 
fixed  erroneous  ideas  have  become  established,  complete  resto- 
ration seldom  occurs. 

§  944.  Treatment — The  great  aim  of  treatment  should  be 


HYSTERIA.  897 

to  prevent  the  appearance  of  the  aggravated  form  of  hysteria. 
With  this  view  the  greatest  attention  should  be  paid  to 
the  early  education  of  children  who  inherit  a  nervous  tem- 
perament, or  who  are  congenitally  predisposed  to  hysteria. 
Such  children  should  be  trained  to  habits  of  unselfishness,  and, 
under  judicious  management,  considerable  progress  may  be 
made  before  the  child  leaves  the  arms  of  the  nurse.  One  great 
difficulty  is  often  experienced  in  such  cases.  When  the  ten- 
dency to  the  disease  is  inherited  through  the  mother,  she  herself 
is  often  irritable  and  explosive  in  disposition,  at  one  time  un- 
necessarily harsh  to  her  children,  again  unduly  indulgent  to 
them,  always  capricious  and  never  firm ;  while  the  father  is  too 
much  occupied  with  business  to  be  able  to  counteract  the  evil 
influence  of  the  mother. 

Under  such  circumstances  the  mother  should  be  advised  to 
place  the  management  of  her  children  as  much  as  possible  in 
the  hands'  of  some  firm  and  judicious  woman,  be  she  nurse, 
relative,  or  governess.  To  train  a  child  into  habits  of  self- 
renunciation  is  the  most  difficult  of  tasks  anyone  can  undertake, 
and  can  only  be  accomplished  by  the  habitual  exercise  of  self- 
control  on  the  part  of  the  teacher. 

During  the  period  of  bodily  development  great  care  should 
be  taken  of  the  health.  The  diet  should  be  plain,  nourishing 
and  abundant,  the  utmost  care  being  taken  that  the  child  is 
not  treated  as  an  invalid,  inasmuch  as  the  observance  of  special 
rules  with  regard  to  diet  is  apt  to  foster  that  feeling  of  self- 
consciousness  which  it  is  so  desirable  to  suppress.  Regular 
hours  for  meals,  going  to  bed  and  getting  up,  should  be 
observed  as  part  of  general  discipline ;  plenty  of  outdoor 
exercise  should  be  taken^  all  the  better  if  it  can  be  made 
agreeable,  or  subservient  to  some  useful  purpose  to  engage  the 
attention.  When  the  young  girl  passes  into  womanhood  she 
ought  to  be  taught  that  she  has  a  field  for  work  and  a  mission 
in  the  world,  and  that  she  is  surrounded  by  human  suffering 
which  she  can  alleviate ;  there  is  little  doubt  that  the  more 
opportunities  of  usefulness  are  multiplied  for  young  ladies  the 
more  the  tendency  to  hysteria  will  diminish. 

But  let  us  now  pass  to  the  treatment  of  the  fully  developed 
disease.    The  exciting  cause  can  only  be  removed  in  a  few  cases 

FFF 


898  HYSTERIA. 

and  even  when  that  is  possible  the  modification  of  the  nervous 
system  already  induced  may  persist.  When  anaemia  exists  the 
usual  treatment  with  iron  and  other  tonics  shouild  be  adopted. 
If  there  be  indigestion  with  flatulence,  bismuth,  charcoal,  alka- 
lies, or  mineral  acids  may  be  administered  with  or  without  a 
better  infusion ;  constipation  demands  the  administration  of 
mild  aperients,  and  atony  of  the  alimentary  canal  quinine,  nux 
vomica,  or  strychnine,  while  uterine  derangements  must  be 
subjected  to  appropriate  treatment.  The  treatment  of  disease 
or  suspected  disease  of  the  generative  organs  in  cases  of  hysteria 
requires  the  greatest  tact  on  the  part  of  the  medical  attendant. 
The  introduction  of  the  catheter,  or  a  vaginal  examination,  if 
the  patient  be  unmarried,  may  lead  to  an  aggravation  of  all  the 
symptoms.  On  the  other  hand,  if  real  disease  exist,  local  treat- 
ment may  be  indispensable  to  success.  When  the  cause  of  the 
hysteria  is  a  moral  one  it  is  often  impossible  for  the  physician 
to  remove  it,  but  even  then  much  may  be  done  by  placing  the 
patient  under  conditions  as  much  as  possible  conducive  to  her 
happiness. 

The  drugs  which  have  been  employed  in  the  treatment  of 
hysteria  are  characterised  by  a  pungent  and  often  disagreeable 
odour.  Assafoetida,  galbanum,  and  valerian  are  the  best  known 
and  most  commonly  used  of  this  class,  and  many  hysterical 
patients  come  to  like  both  the  taste  and  smell  of  these  nauseous 
substances.  They  do  not  appear  to  produce  a  permanent  in- 
fluence upon  the  disease,  although  they  may  be  of  use  in 
removing  flatulence  and  other  troublesome  symptoms. 

When  general  hypersesthesia  and  sleeplessness  exist,  it  may 
be  necessary  to  administer  narcotics,  morphia  injected  subcu- 
taneously  being  the  best.  The  patients,  however,  should  never 
be  allowed  to  take  morphia  or  other  narcotic  at  their  own  dis- 
cretion. Bromide  of  potassium  is  a  valuable  agent  in  some 
cases,  and  where  there  is  much  sleeplessness  its  efficacy  is 
increased  by  being  combined  with  chloral. 

The  electrical  treatment  of  particular  symptoms  of  hysteria 
is  sometimes  followed  by  improvement  of  the  general  con- 
dition. Beard  and  Bockwell  have  recently  recommended  that 
the  entire  surface  of  the  body  be  treated,  in  successive  portions, 
with  tolerably  strong  induced  currents,  and  this  treatment  has 


HYSTERIA.  899 

been  found  very  successful,  although  its  efficiency  depends  pro- 
bably on  the  mental  impression  produced  rather  than  on  the 
local  action  of  the  current.  The  influence  exerted  by  counter 
irritation  of  various  kinds  appears  also  to  be  largely  due  to  the 
mental  impression  made. 

The  most  important  part  of  the  treatment  of  hysteria  con- 
sists of  the  moral  management  of  the  patient.  One  of  the 
first  requisites  for  treatment  is  that  the  physician  should 
possess  the  entire  confidence  of  the  patient  and  her  friends.  An 
essential  condition  for  success  is  that  the  physician  be  himself 
convinced  that  hysteria  is  a  real  and  not  a  sham  disease,  and 
that  the  treatment  prescribed  is  a  real  and  not  a  sham  treat- 
ment. There  is  probably  no  disease  which  a  medical  man 
has  to  treat  which  makes  so  many  demands  upon  his  firmness, 
self-control,  and  ingenuity  as  hysteria.  He  must  be  able  to 
sympathise  with  the  feelings  of  the  patient  in  order  to  commancU 
her  confidence,  but  if  his  sympathy  degenerate  into  false 
sentiment  or  into  the  slightest  exaggeration  of  manner  he  will 
only  be  administering  to  the  morbid  craving  for  sympathy  which 
is  at  the  root  of  the  disease,  while  on  the  other  hand  the 
slightest  attempt  to  laugh  down  the  patient's  fancies  may  be 
fatal  to  success.  Earnestness  of  purpose,  determination,  and 
fertility  of  resource  are  all  called  into  requisition  in  the  treat- 
ment of  hysteria.  The  instructions  given  to  the  patient  should 
be  plain  and  such  as  can  be  readily  carried  out ;  they  ought 
at  the  same  time  to  task  to  some  extent  her  voluntary  efforts. 
When  once  instructions  are  issued  the  most  implicit  obedience 
to  them  should  be  insisted  upon,  for  laxity  in  enforcing 
observance  of  rules  argues  want  of  confidence  in  their  efficacy. 
The  voluntary  efforts  of  the  patient  should  be  daily  exercised 
by  making  progressively  increasing  demands  upon  them.  And 
as  the  power  of  will  becomes  strengthened,  emotional  excite- 
ment will  diminish  in  corresponding  degree. 

Instead  of  exciting  the  dormant  will  into  activity  by 
graduated  exercises,  this  can  frequently  be  accomplished  at 
once  by  anything  which  acts  powerfully  on  the  imagination. 
Hysterical  patients,  who  have  been  bed -ridden  for  years,  have 
been  known  to  get  out  of  bed,  and  walk  under  the  influence  of 
a  strong  emotion,  or  after  having  the  imagination  powerfully 


900  HYSTERIA. 

acted  upon,  so  that  the  rapid  change  from  utter  helplessness 
to  full  motor  power  appears  almost  like  a  miracle.  Whatever 
may  be  the  reason  of  it,  there  can  be  very  little  doubt  that  such 
wonderful  cures  are  generally  effected  by  clergymen  or  irregular 
practitioners,  and  rarely  by  the  sedate,  highly  respectable, 
regular  practitioner. 

Painful  remedies  used  with  moderation  and  humanity  are 
sometimes  very  useful,  partly  by  appealing  to  the  imagination. 
Of  these  remedies,  the  faradic  current  is  probably  the  most 
generally  useful,  and  a  subcutaneous  injection  of  morphia  is 
for  a  similar  reason  more  efficacious  than  the  internal  admini- 
stration. Simple  water  has  been  successfully  substituted  for 
the  narcotic  injection,  so  great  is  the  influence  of  mental 
impression. 

It  is  sometimes  possible  to  cure  severe  hysterical  symptoms 
by  means  of  threats,  sudden  fright,  or  moral  shock.  An  un- 
expected shower  of  cold  water  may  have  the  desired  effect, 
and  at  other  times  the  threat  of  the  actual  cautery  is  efficacious. 
Charcot  mentions  the  case  of  a  woman  who  had  suffered  for 
more  than  two  years  from  permanent  contracture  of  one  of 
the  lower  extremities,  which  suddenly  vanished  on  account 
of  the  moral  shock  caused  by  an  accusation  of  theft  brought 
against  her ;  a  second  also  in  whom  contracture  of  four  years 
standing  suddenly  disappeared  in  consequence  of  a  stern 
admonition  given  her ;  and  a  third  in  whom  a  like  condition 
vanished  on  account  of  a  sudden  disappointment.  Great  judg- 
ment must  be  exercised  in  the  employment  of  such  means, 
inasmuch  as  the  disease  may  be  aggravated  instead  of  amelio- 
rated by  them. 

Hysterical  patients  are  treated  with  much  greater  success 
in  the  wards  of  an  hospital  than  in  their  own  homes.  In 
aggravated  cases,  therefore,  the  patient  should  be  removed 
from  her  home  and  relations  and  placed  for  a  period  of  some 
months  either  in  a  public  institution,  or  under  the  care  of 
complete  strangers. 

During  hysterical  fits  the  patients  usually  take  care  not  to 
injure  themselves,  but  it  is  often  necessary  to  prevent  respiration 
being  impeded  by  clothing.  I  have  always  found  it  better 
not    to    allow    a    hysterical    woman   to   toss   about   violently 


HYSTERIA.  901 

in  all  directions,  but  to  hold  her  down  gently  but  firmly,  and 
to  prevent  her  struggles.  The  best  method  of  securing  the 
patient  is  to  place  an  attendant  on  each  side  of  her,  and  to 
direct  each  to  grasp  one  wrist  with  one  hand  and  to  hold  the 
shoulder  firmly  down  to  the  bed  or  floor  with  the  other ;  if 
necessary  the  patient's  legs  must  be  held  down.  It  is  remark- 
able how  soon  a  hysterical  patient  ceases  to  struggle  when  she 
finds  that  she  is  held  as  in  a  vice.  So  long  as  the  patient  can 
shake  herself. free  from  her  attendants,  so  long  is  the  struggle 
apt  to  be  maintained,  but  when  once  she  feels  that  she  is 
thoroughly  restrained,  and  that  her  efforts  do  not  find  outward 
expression,  she  generally  ceases  to  struggle.  The  most  usual 
remedy  for  arresting  the  attack  is  to  dash  cold  water  on  the 
face  and  neck;  although  this  is  a  useful  method  occasionally 
it  is  by  no  means  the  best.  The  plan  suggested  by  Dr.  Hare 
of  forcibly  holding  the  mouth  and  nose  of  the  patient  so  as  to 
prevent  her  from  breathing  is  very  effectual.  In  my  own  prac- 
tice the  administration  of  an  emetic  was  at  one  time  a  favourite 
method  of  arresting  an  attack.  Strong,  vigorous  servant-maids 
sometimes  suffer  from  violent  hysterical  convulsions,  and  in 
them  I  was  in  the  habit  of  giving  an  emetic  dose  of  the 
tartrate  of  antimony.  In  most  cases,  however,  the  sulphate  of 
zinc  is  safer  if  less  efficient. 

If  the  attack  be  caused  by  some  peripheral  irritation,  its. 
removal  may  arrest  it.  Severe  attacks  have  sometimes  ceased 
after  the  rectification  of  a  misplaced  uterus.  In  cases  of  hystero- 
epilepsy  Charcot  has  succeeded  in  arresting  the  attacks  by  firm 
compression  of  the  hypergesthetic  ovary,  but  this  does  not 
appear  to  be  a  means  applicable  for  the  convulsive  attacks  of 
ordinary  hysteria.  Large  doses  of  the  bromide  of  potassiuua 
exert  a  favourable  influence  on  the  fits  of  hystero-epilepsy,  but 
this  remedy  is  not  of  much  value  in  the  common  form  of 
convulsive  attack. 

Limited  spasms  in  hysteria  are  best  removed  by  general 
treatment  and  moral  management,  although  local  treatment  and 
special  remedies  are  occasionally  found  useful.  In  the  case 
of  patients  suffering  from  obstinate  globus,  Erb  recommends 
the  repeated  application  of  the  constant  current,  the  anode 
being  placed  at  the  side  of  the  larynx. 


902  HYSTERIA. 

For  spasms  of  the  stomach  and  bowels,  sometimes  warm,  at 
other  times  cold  applications  to  the  abdomen  are  useful ;  opium, 
belladonna,  quinine,  valerian,  or  other  drugs  of  the  same  class 
may  be  given  internally. 

Vomiting  is  one  of  the  most  troublesome  and  obstinate 
symptoms  of  hysteria.  It  is  usual  to  regulate  the  diet,  and 
.to  give  only  bland  and  easily  digestible  substances,  such  as 
milk  cooked  in  various  forms,  but  this  method  is  not  always 
successful.  Sometimes  the  patients  retain  highly-seasoned  food 
better  than  bland  diet,  and  the  vomiting  may  cease  if  they 
are  allowed  to  eat  raw  ham  or  raw  mince-meat  well  peppered. 
Care,  however,  should  by  taken  that  the  nature  of  the  case  is 
clear.  In  spastic  as  well  as  in  paralytic  retention  of  urine  warm 
sitz-baths  will  often  bring  relief;  when  they  are  unsuccessful 
the  catheter  should  be  employed  in  case  the  bladder  becomes 
distended. 

In  hysterical  paralysis  electricity  is  the  best  remedy,  and  the 
application  of  strong  faradic  currents  to  the  paralysed  nerves  and 
muscles  is,  as  a  rule,  successful.  Galvanisation  of  the  spinal 
cord  is  useful  in  hysterical  paraplegia.  Aphonia  may  at  first  be 
treated  by  external  faradisation,  but  in  obstinate  cases  recourse 
must  be  had  to  the  intralaryngeal  application. 

Passive  movements  and  frictions  of  the  limbs  with  or  without 
embrocations  are  also  useful  as  aids  in  treatment,  and  Reynolds 
strongly  recommends  the  application  of  narrow  strips  of 
blister  passing  completely  round  the  affected  limbs.  Com- 
pression of  the  larynx  with  the  fingers  sometimes  temporarily 
restores  lost  speech,  and  a  similar  effect  may  be  obtained  by 
passing  a  strip  of  adhesive  plaster  across  the  larynx  so  as  to 
partially  surround  the  neck.  Hysterical  tympanites  may  at 
times  be  dispersed  by  powerful  faradisation  of  the  abdominal 
muscles  or  even  by  firm  compression  of  the  abdomen,  but  in 
aggravated  cases  the  introduction  of  the  intestinal  tube  may  be 
necessary. 

Hysterical  anaesthesia  is  best  treated  by  powerful  faradic 
currents  applied  by  means  of  the  dry  metallic  brush.  Charcot 
has  succeeded  in  removing  hysterical  hemiangesthesia  by  applying 
various  metals  to  the  cutaneous  surface.  This  method  of  treat- 
ment was  introduced  by  Burq,  but  it  would  appear  that  the 


HYSTERIA.  903 

ansesthetic  condition  is  only  transferred  from  the  affected  to 
the  opposite  side  of  the  body.  It  is  somewhat  premature  to 
pass  any  opinion  with  respect  to  the  success  of  this  practice. 
So  long  as  certain  "passes"  over  the  surface  of  the  body  can 
induce  a  condition  of  general  anaesthesia,  such  as  that  met  with 
in  the  mesmeric  state,  there  is  nothing  absurd  in  supposing 
that  similar  passes  and  the  application  of  coins  to  the  surface 
may  have  a  curative  effect  in  conditions  of  partial  anaesthesia. 

Hysterical  neuralgia  and  hypersesthesia  demand  the  employ- 
ment of  narcotics  and  anesthetics.  Caffein,  guarana,  and 
chloride  of  ammonium  are  useful  in  hysterical  cephalalgia. 
Chloral  hydrate  given  in  scruple  and  half-drachm  doses  to 
procure  sleep  is  occasionally  useful,  and  inhalation  of  chloro- 
form may  be  necessary  in  order  to  overcome  contractures  of 
muscles. 


904 


CHAPTER    V. 


CATALEPSY,    TRANCE,  ECSTASY,   AND   OTHER   ALLIED 
CONDITIONS. 


(I.)    CATALEPSY. 

Catalepsy  is  characterised  by  attacks  of  partial  or  complete 
loss  of  consciousness,  accompanied  by  stiffening  of  the  voluntary 
muscles,  having  the  peculiarity  that  the  limbs  retain  for  a 
relatively  long  period  the  positions  in  which  they  may  be  placed 
by  passive  motion. 

§  945.  Etiology. — Catalepsy  often  occurs  as  one  of  the  many 
manifestations  of  hysteria,  while  at  other  times  it  is  caused 
by  chronic  cerebral  disease,  such  as  softening,  tubercular 
meningitis,  and  tumours.  In  some  cases  the  cataleptic  con- 
dition appears  to  be  premonitory  of  true  epileptic  attacks. 
Some  cases,  however,  cannot  be  traced  to  either  of  these  causes, 
and  then  catalepsy  may  be  called  idiopathic  or  essential; 
cases  of  the  latter  form  are  observed  in  families  who  inherit 
a  decided  neurotic  disposition.  The  disease  is  most  frequently 
observed  about  the  age  of  puberty,  but  it  has  been  met  with 
as  early  as  five  years  of  age,  and  occasionally  in  advanced  age. 
The  two  sexes  appear  to  be  equally  liable  to  the  idiopathic 
variety,  but  the  hysterical  is  almost  exclusively  observed  in  the 
female.  The  excitiog  causes  of  idiopathic  c&,talepsy  are  gastric 
and  intestinal  irritation,  and  great  emotional  disturbance. 
Malarial  infection  is  said  to  have  caused  typical  attacks  of 
catalepsy. 

§  946.  Symptoms. — The  cataleptic  attack  is  sometimes  pre- 
ceded by  premonitory  symptoms,  such  as  headache,  vertigo. 


CATALEPSY.  905 

trembling  of  individual  muscles,  and  an  undefined  sense  of 
discomfort.  As  a  rule,  the  attack  begins  abruptly ;  the 
movements  of  the  patient  are  suddenly  arrested,  it  may  be 
while  he  is  speaking  or  performing  some  action  ;  the  face 
becomes  deadly  pale ;  the  respirations  are  slow  and  tranquil ; 
the  pulse  is  soft ;  and,  although  consciousness  is  lost,  the  atti- 
tude of  the  patient  at  the  time  of  the  seizure  is  retained. 
The  muscles  in  action  at  the  beginning  of  the  attack  appear  to 
be  the  first  to  become  rigid,  but  the  spasm  rapidly  extends,  as 
a  rule,  to  all  the  voluntary  muscles,  although  occasionally  it  is 
partial  or  unilateral.  The  affected  muscles  feel  firm,  and  offer 
resistance  to  passive  movements  of  the  limbs ;  when  once  this 
resistance  is  overcome,  the  limbs,  head,  and  neck,  or  features 
may  be  placed  in  constrained  positions,  which  they  retain 
for  a  comparatively  long  period.  After  the  first  resistance  of 
the  muscles  has  been  overcome  the  limbs  possess  a  flexibility 
and  pliability,  which  has  been  compared  to  that  of  soft  wax. 
It  has  consequently  been  named  fiexibilitas  cerea.  This  con- 
dition of  the  muscles  enables  the  limbs  to  be  moulded  in 
any  position  compatible  with  the  rigidity  of  bones  and  inex- 
tensibility  of  ligaments,  and  the  constrained  attitudes  in 
which  the  limbs  may  be  placed  are  maintained  without  change 
during  the  whole  course  of  the  attack.  "  I  was  shown,"  says 
Dr.  Wilks,  "  a  man  in  Morningside  whom  they  could  mould  in 
any  position.  Whilst  in  bed  on  his  back  they  could  arrange 
his  arms  and  legs  in  any  posture  and  there  his  limbs  would 
remain.  Dr.  Savage  has  a  case  in  Bethlem  of  a  young  man 
who  will  keep  his  arm  stretched  out  for  two  hours,  and  stand 
on  one  leg  for  a  great  length  of  time.  If  made  to  follow 
another  patient,  he  will  continue  to  do  so  until  he  is  stopped." 
But  even  during  the  cataleptic  condition  the  muscular  stiffness 
does  not  persist  in  its  full  intensity  for  a  lengthened  period. 
After  some  minutes  the  stiffness  diminishes  somewhat,  so  that 
the  arm,  for  instance,  when  raised  horizontally  falls  lower  by 
its  own  weight,  and  the  limb  undergoes  a  slight  trembling, 
indicating  the  approaching  exhaustion  of  the  muscles. 

Consciousness  is  usually  abolished,  but  not  in  all  cases.  A 
certain  amount  of  consciousness  may  be  retained  in  the  early 
stage  of  the  attack  or  be  present  throughout,  so  that  strong 


906  CATALEPSY. 

peripheral  irritation  may  cause  pain  which  will  be  remembered 
by  the  patient.  Reflex  irritability  is  sometimes  lost ;  at  other 
times  certain  reflex  actions,  such  as  closure  of  the  eyelids  on 
touching  the  conjunctiva,  are  retained.  The  electric  contrac- 
tility of  the  muscles  remains  ;  and,  according  to  the  observations 
of  Benedikt,  the  galvanic  irritability  of  the  nerves  is  increased 
during  the  attack,  but  becomes  rapidly  diminished  during  the 
intervals.  In  one  case  observed  by  Rosenthal  the  electrical 
reaction  of  the  nerves  to  both  currents  was  perfectly  normal ; 
in  another  it  was  increased. 

The  organic  functions  are  not  usually  seriously  interfered 
with.  The  respiration  may  be  normal,  but  is  generally  slow 
and  shallow.  The  pulse  is  slow,  soft,  and  compressible.  The 
temperature  is  generally  lowered,  and  at  times  the  surface  of 
the  body  becomes  icy  cold.  When  the  surface  of  the  body 
is  cold,  and  the  pulse  at  the  wrist  and  respiration  are  almost 
imperceptible,  the  condition  may  be  mistaken  for  real  death. 

The  attack  of  catalepsy  is  sometimes  very  brief,  lasting 
only  a  few  minutes,  at  other  times  several  hours  or  days. 
Attacks  described  as  being  very  protracted  are  in  reality  made 
up  of  a  succession  of  these,  separated  from  one  another  by  in- 
tervals in  which  the  patients  recover  either  wholly  or  partially. 
The  seizures  sometimes  disappear  quite  suddenly,  and  the 
patients  at  once  recover  full  consciousness  and  immediately 
resume  the  actions  which  had  been  interrupted.  As  a  rule, 
iiowever,  recovery  is  gradual,  patients  at  first  being  stupefied  as 
if  awaking  from  a  profound  sleep,  a  certain  amount  of  muscular 
stiffness  remaining  for  some  time,  which  renders  motion  difficult 
and  slow. 

In  simple  catalepsy  no  mental  disorder  is  observed  in  the 
intervals  between  the  attacks,  but  when  it  is  merely  a  symptom 
of  profound  nervous  disease  the  intervals  may  be  characterised 
by  the  occurrence  of  hysterical  convulsions,  delirium,  maniacal 
attacks,  and  hallucinations,  or  the  catalepsy  may  be  associated 
with  ecstasy  and  somnambulism. 

§  947.  Course. — The  course  of  catalepsy  is  usually  chronic, 
extending  over  many  years.  Some  individuals  suffer  only  from 
a  small  number  of  attacks  separated  by  intervals  of  many  years. 


I 


TRANCE — ECSTASY.  907 

Others,  again,  have  frequent  periodical  attacks.  In  hysterical 
catalepsy  the  slightest  external  influence  may  suffice  to  provoke 
a  paroxysm.  Catalepsy  of  malarial  origin  follows  the  regular 
course  of  other  malarial  neuroses ;  they  are  sometimes  accom- 
panied by  fever  and  sweating,  and  generally  yield  to  the  usual 
antiperiodic  remedies.  Cases  caused  by  sudden  fright  or  injury 
may  also  run  an  acute  course,  the  disease  terminating  after  a 
single  attack  or  after  a  series  of  them.  Cataleptic  attacks  are 
hardly  ever  fatal  of  themselves. 

(II.)    TEANCE. 

§  948.  In  this  condition  the  patient  lies  for  days  together 
in  an  apparently  insensible  condition  without  eating  or  drinking. 
The  state  of  complete  insensibility  is  not,  however,  continuous, 
inasmuch  as  there  occur  periods  during  which  the  patient 
notices  those  around  her,  and  may  partake  of  small  quantities 
of  food.  The  condition  of  the  patient  is  not,  indeed,  unlike  that 
of  a  hibernating  animal.  In  the  state  of  trance  the  patient 
usually  lies  in  a  warm  room,  well  covered  with  clothing,  so 
that  little  heat  is  lost  by  radiation  ;  the  mental  functions  are  in 
abeyance,  indicating  that  the  molecular  changes  which  are  the 
correlatives  of  mental  actions  have  ceased ;  and  all  muscular 
movements  are  suspended  with  the  exception  of  the  cardiac 
contractions,  and  slight  respiratory  movements.  Under  such  cir- 
cumstances the  amount  of  waste  must  be  small.  If  Dr.  Tanner 
(and  there  are  no  grounds  for  believing  that  any  deception 
was  practised  by  him),  with  all  the  waste  implied  by  the 
possession  of  active  mental  faculties,  outbursts  of  temper, 
walking  and  driving  in  the  open  air,  could  live  forty  days 
without  food,  it  may  be  inferred  that  persons  in  the  state  of 
trance  might  live  fasting  for  a  much  longer  period.  The 
physician  must,  of  course,  be  on  his  guard  against  deception  in 
cases  of  trance. 

(III.)    ECSTASY. 

§  949.  This  condition  is  closely  allied  to  trance,  the  patient 
being  insensible  to  outward  impressions  in  both.  In  ecstasy 
the  mind  is  absorbed  with  some  fixed   idea,  generally  of  a 


908  SOMNAMBULISM    AND    HYPNOTISM. 

religious  character,  and  the  patient  becomes  oblivious  of 
surrounding  events  and  objects.  The  limbs  are  motionless,  and 
often  fixed  in  maintaining  a  particular  attitude ;  the  breathing 
is  slow  and  feeble ;  the  pulse  is  almost  imperceptible ;  the  eyes 
are  often  bright  and  animated ;  and  the  countenance  has  an 
expression  of  rapture  (Maudsley). 

(IV.)     SOMNAMBULISM  AND   HYPNOTISM. 

§  950.  In  somnamhulism  the  patients  appear  to  be  wholly 
unconscious,  yet  they  walk,  climb,  and  avoid  obstacles,  and  may 
manifest  greater  strength,  agility,  and  precision  of  muscular 
adjustments  than  during  waking  hours. 

Hypnotism  or  mesmerism  is,  as  Maudsley  remarks,  a  kind 
of  artificially  induced  somnambulism.  The  subject,  who  is 
probably  always  of  a  neurotic  temperament,  is  induced  to  look 
steadily  at  the  operator,  the  latter  attracting  his  attention  by 
making  a  few  gentle  "  passes"  with  his  hand.  Mr.  Braid,  of 
Manchester,  directed  the  person  to  look  upon  a  disc  or  some 
bright  object  held  in  front  of  and  a  little  above  the  level  of  the 
eyes.  After  a  short  time  there  is  a  slight  tremor  of  the  eyeballs 
of  the  subject,  his  pupils  dilate,  and  he  falls  into  the  mesmeric 
condition.  In  this  state  the  mental  functions  are  abolished,  and 
all  the  actions  of  the  subject  are  afterwards  determined  by 
the  suggestions  of  the  operator.  Under  the  influence  of  these 
suggestions  the  subject  may  sing,  recite  poetry,  and  perform 
the  most  absurd  and  outrageous  actions.  He  may  be  made  to 
eat  a  raw  cabbage  amidst  all  the  outward  signs  of  enjoyment 
to  appease  a  suggested  hunger;  he  may  spit  out  pure  water 
given  him  to  drink  with  all  the  signs  of  disgust,  on  the  sugges- 
tion that  it  is  bitter  and  nauseous,  or  drink  infusion  of 
wormwood  with  apparent  relish  on  being  told  that  it  is  an 
agreeable  beverage  ;  or  he  may  be  made  to  sneeze  violently  on 
being  asked  to  take  a  pinch  of  snuff  from  an  empty  box.  Hyste- 
rical patients  may  be  thrown  into  a  condition  of  trance  or  of 
catalepsy,  or  one  half  of  the  body  may  be  thrown  into  trance 
and  the  other  half  into  catalepsy,  by  being  made  to  look  upon  a 
bright  light  (Charcot).  A  condition  much  resembling  the  hyp- 
notic state  is  sometimes  induced  by  disease.     A  curious  case  of 


I 


SOMNAMBULISM    AND    HYPNOTISM.  909 

this  kind  is  transcribed  by  Dr.  Wilks  from  Galignani,  and  as 
the  case  is  a  remarkable  one  in  many  ways  I  quote  it  at  length. 

A  Living  Automaton. — A  curious  patient  is  just  now  an  inmate  of  Dr. 
Mesnet's  ward  at  the  Hopital  St.  Antoine.  His  profession  was  that  of  a 
singer  at  the  Caf^s  Chantants.  During  the  war  of  1870-71  he  was  hit 
over  the  left  ear  by  a  musket  bullet,  which  carried  off  about  2^  inches  of 
the  parietal  bone,  and  laid  bare  the  brain  on  the  left  side.  This  led  to  a 
temporary  paralysis  of  the  members  on  the  opposite  side,  as  is  always  the 
case ;  but  he  was  eventually  cured  of  this,  while  the  tremendous  wound 
on  the  skull  began  to  heal,  so  that  after  a  time  he  could  resmne  his  pro- 
fessional duties  at  the  caf6s  to  the  satisfaction  of  the  pubUc.  Suddenly, 
however,  he  was  seized  with  nervous  symptoms,  lasting  from  24  to  48 
hours,  and  of  such  an  extraordinary  nature  that  it  was  considered  safe  to 
take  him  to  the  hospital.  His  malady  is  easier  to  illustrate  by  examples 
than  to  define.  When  he  is  in  his  fit  he  has  no  sensitiveness  of  his  own, 
and  will  bear  physical  pain  without  being  aware  of  it ;  but  his  will  may 
be  influenced  by  contact  with  exterior  objects.  Set  him  on  his  feet,  and, 
as  soon  as  they  touch  the  ground,  they  awaken  in  him  the  desire  of  walking ; 
he  then  marches  straight  on  quite  steadily,  with  fixed  eyes,  without  saying 
a  word,  or  knowing  what  is  going  on  about  him.  If  he  meets  with  an 
obstacle  on  his  way  he  will  touch  it,  and  try  to  make  out  by  feeling  what 
it  is,  and  then  attempt  to  get  out  of  its  way.  If  several  persons  join 
hands  and  form  a  ring  around  him,  he  will  try  to  find  an  opening  by 
repeatedly  crossing  over  from  one  side  to  the  other,  and  this  without 
betraying  the  slightest  consciousness  or  impatience.  Put  a  pen  into  his 
hand ;  this  will  instantly  awaken  in  him  the  desire  of  writing ;  he  will 
fumble  about  for  ink  and  paper,  and,  if  these  be  placed  before  him,  he  will 
write  a  very  sensible  business  letter  ;  but,  when  the  fit  is  over,  he  will 
recollect  nothing  at  all  about  it.  Give  him  some  cigarette  paper,  and  he 
will  instantly  take  out  his  tobacco  bag,  roU  a  cigarette  very  cleverly,  and 
light  it  with  a  match  from  his  own  box.  Put  them  out  one  after  another, 
he  will  try  from  first  to  last  to  get  a  light,  and  put  up  in  the  end  with  his 
ill-success.  But  ignite  a  match  yourself,  and  give  it  him,  he  will  not  use 
it,  and  let  it  burn  between  his  fingers.  Fill  his  tobacco  bag  with  anything, 
no  matter  what — shavings,  cotton,  lint,  hay,  &c.— he  will  roll  his  cigarette 
just  the  same,  light  and  smoke  it  without  perceiving  the  hoax.  But, 
better  stiE,  put  a  pair  of  gloves  into  his  hand,  and  he  will  put  them  on  at 
once ;  this,  reminding  him  of  his  profession,  will  make  him  look  for  his 
music.  A  roll  of  paper  is  then  given  to  him,  upon  which  he  assumes  the 
attitude  of  a  singer  before  the  public,  and  warbles  some  piece  of  his  reper- 
tory. If  you  place  yourself  before  him  he  will  feel  about  on  your  person, 
and,  meeting  with  your  watch,  he  will  transfer  it  from  your  pocket  to  his 
own  ;  but,  on  the  other  hand,  he  will  allow  you,  without  any  resistance  or 
impatience  whatever,  to  take  it  back  again. 


910  SOMNAMBULISM    AND    HYPNOTISM. 

§  951.  Morbid  Anatomy  and  Physiology. — Post-mortem 
examinations  have  only  revealed  changes  in  those  cases  in  which 
catalepsy  and  its  allies  are  mere  symptoms  of  grave  organic 
disease.  Schwartz  reports  the  case  of  a  boy  who,  after  an 
injury,  suffered  at  first  from  an  affection  resembling  chorea,  and 
later  cataleptoid  attacks,  and  who,  after  two  years,  died  from 
ansemia  and  marasmus.  The  autopsy  revealed  serous  effusion 
in  the  arachnoid,  softening  of  the  corpus  striatum  and  optic 
thalamus,  especially  of  the  left  side;  and  a  brownish-red,  jelly- 
like mass,  covering  the  spinal  dura  mater  along  the  posterior 
surface  of  the  cord  from  the  cervical  to  the  lumbar  enlargement. 
Meissner  examined  a  man,  47  years  of  age,  who  suffered  from 
catalepsy  for  six  years,  and  in  the  three  last  years  of  his  life 
from  maniacal  and  epileptic  symptoms,  with  paralysis  of  the 
right  side ;  he  found  an  epithelioma  growing  from  the  dura 
mater  in  the  anterior  fossa  over  the  ethmoid  bone ;  the  ante- 
rior third  of  the  right  cerebral  hemisphere,  as  well  as  the  right 
corpus  striatum,  was  much  softened,  Lasegue  found  no  change 
in  the  brains  of  two  men  affected  with  catalepsy  examined 
by  him. 

The  information  obtained  from  post-mortem  examination  is 
as  yet  far  too  scanty  to  throw  much  light  on  the  pathology  of 
the  disease.  One  noteworthy  fact  in  connection  with  the 
slighter  forms  of  cataleptic  attacks  is  their  similarity  to  some 
cases  of  the  petit  mal  of  epilepsy.  It  is  a  somewhat  significant 
fact  that  in  Meissner's  case  of  catalepsy  the  disease  was  situated 
in  the  prsefrontal  region  of  tbe  cerebral  hemispheres.  A 
functional  or  organic  lesion  of  the  cortex  of  the  cerebrum  might 
no  doubt  account  for  the  sudden  loss  of  consciousness,  but  the 
most  characteristic  features  of  catalepsy — the  muscular  rigidity 
and  flexibilitas  cerea — are  still  unexplained.  Most  authors 
believe  that  the  cataleptic  rigidity  is  only  an  increase  of  the 
normal  tonus  of  the  voluntary  muscles,  and  some  think  that 
the  diminution  or  loss  of  voluntary  innervation  which  occurs  in 
catalepsy  causes  an  increase  in  the  reflex  tonus  of  the  muscles, 
just  as  reflex  excitability  is  increased  by  the  removal  of  the 
cerebral  hemispheres  in  frogs.  But  no  amount  of  increase  of 
the  reflex  tonus  would  account  for  the  condition  known  as 
flexibilitas  cerea,  and  what  is  a  still  more  fatal  objection  to  this 


1 


SOMNAMBULISM   AND   HYPNOTISM.  911 

theory  is  that  general  reflex  irritability,  instead  of  being  increased 
in  catalepsy,  is  on  the  contrary  often  much  diminished  or 
abolished. 

We  have  already  seen  that  complete  hemiansesthesia  is 
probably  caused  by  a  temporary  or  permanent  arrest  of  the 
functions  of  the  centripetal  fibres  in  their  ascent  through  the 
internal  capsule,  or  of  that  part  of  the  cortex  of  the  brain  which 
is  supplied  by  the  posterior  cerebral  artery.  Suppose  now  that 
a  complete  bilateral  hemiansesthesia  exists,  what  would  be  the 
condition  of  the  patient  1  There  would  be  complete  loss  of  every 
form  of  cutaneous  and  muscular  sensibility  as  well  as  of  sensa- 
tion in  the  bones  and  joints  ;  there  would  be  loss  of  taste  on  both 
sides  of  the  tongue,  and  of  smell  in  both  nostrils ;  and  instead 
of  there  being  amblyopia  and  partial  deafness  on  one  side, 
as  in  hemianaBsthesia,  there  would  be  complete  blindness  and 
deafness  on  both  sides,  inasmuch  as,  according  to  the  hypothesis, 
the  sensory  centres  in  both  hemispheres  either  have  ceased  to 
act  or  the  impressions  made  on  the  peripheral  sense  organs  fail 
to  be  conducted  to  them.  But  impressions  made  on  the  peri- 
phery would,  however,  reach  the  cortex  of  the  brain  through 
the  optic  thalamus,  and  the  subject  of  bilateral  hemiansesthesia, 
although  effectually  cut  off  from  the  external  world  so  far  as 
the  anatomical  substratum  of  consciousness  is  concerned,  would 
perform  various  complicated  actions  in  response  to  peripheral 
impressions,  but  without  being  attended  by  consciousness.  The 
condition  would,  indeed,  be  very  similar  to  that  observed  in 
somnambulism,  the  mesmeric  state,  and  various  post- epileptic 
and  allied  conditions. 

§  952.  Diagnosis. — During  the  presence  of  muscular  stiffening 
and  flexibilitas  cerea,  the  diagnosis  can  present  no  difficulties. 
Only  very  cleverly  executed  simulation  could  give  rise  to  any 
doubt ;  and  in  these  cases  careful  testing  of  the  sensibility,  reflex 
irritability,  and  electrical  reactions,  along  with  comprehensive 
observation  of  the  concomitant  symptoms,  ought  to  be  suffi- 
cient to  afford  a  safeguard  against  deception. 

§  953.  Prognosis. — The  prognosis  of  uncomplicated  cases  of 
catalepsy  is  always  favourable  as  regards  life ;  but  with  respect 


912  SOMNAMBULISM  AND  HYPNOTISM. 

to  complete  recovery  it  is  unfavourable.  Cases  arising  from 
malarial  infection  afford  a  better  prognosis,  and  the  same  may 
be  said  with  respect  to  acute  attacks  occurring  in  comparatively 
healthy  persons  as  the  result  of  injuries  and  mental  shocks. 

§  954.  Treatment. — The  aims  of  treatment  in  catalepsy  are 
to  arrest  the  attacks  and  to  prevent  their  return.  The  latter 
indication  can  be  best  effected  when  the  cause  can  be  removed ; 
in  catalepsy  due  to  malaria,  quinine  alone,  or  combined  with 
morphia,  may  effect  a  complete  cure.  Favourable  results  have 
been  obtained  by  the  use  of  tonics,  iron,  ergot,  morphia,  the 
cold  douche,  and  the  faradic  current.  The  galvanic  current 
has  hitherto  proved  useless. 

Attempts  to  put  an  end  to  the  attack  itself  have  not  been 
very  successful.  A  slight  peripheral  irritation  may  arouse 
patients  in  hysterical  catalepsy,  but  in  the  idiopathic  form  very 
strong  cutaneous  irritation  has  often  no  influence.  In  pro- 
tracted cases  artificial  feeding  by  the  stomach  pump  and 
nutritious  enemata  must  be  had  recourse  to. 

Trance  must  be  treated  on  the  same  general  principles  as 
hysteria,  while  those  who  are  liable  to  attacks  of  somnam- 
bulism ought  to  have  their  bedroom  windows  and  doors  well 
fastened  at  night. 


913 


CHAPTEE  VI. 


EPILEPSY    AND    ECLAMPSIA. 


(I.)    EPILEPSY. 

Epilepsy  is  a  chronic  functional  disease  of  the  nervous  system, 
characterised  by  recurring  paroxysms  of  impairment  or  loss 
of  consciousness,  accompanied  generally  by  partial  or  general 
convulsions. 

§  955.  Etiology. — Hereditary  predisposition  plays  an  impor- 
tant part  in  the  production  of  epilepsy.  The  transmission  may 
be  direct,  as  when  the  progeny  of  an  epileptic  parent  are 
affected ;  or  indirect,  when  one  or  more  generations  escape, 
and  the  disease  reappears  in  the  descendants.  But  in  other 
cases  the  hereditary  tendency  is  still  more  indirect.  The 
family  of  the  patient  may  have  a  proclivity  to  nervous  disease, 
declaring  itself  as  insanity  in  one  member,  as  hysteria  in  a 
second,  indulgence  in  alcoholic  excess  in  a  third,  neuralgia  in 
a  fourth,  and  epilepsy  in  a  fifth,  while  other  members  may  only 
exhibit  the  slighter  forms  of  instability  termed  nervousness. 
A  hereditary  taint  may  be  traced  in  rather  more  than  one-third 
of  all  cases  (Reynolds,  Gowers).  The  children  of  consangui- 
neous marriages  appear  to  suffer  from  epilepsy  in  greater 
proportion  than  other  children.  All  family  peculiarities,  whether 
good  or  bad,  are  intensified  in  the  children  by  intermarriage;  and 
when  both  parents  inherit  an  unstable  nervous  system  the 
probability  of  some  nervous  disorder  appearing  in  the  progeny  is 
greatly  increased.  Under  these  circumstances  one  or  more  of 
the  children  may  suffer  from  epileptic  convulsions  when  the 
parents  manifest  only  nervousness,  neuralgia,  or  hysteria.  The 
GGG 


914  EPILEPSY. 

disease  is  transmitted  more  frequently  through  the  mother  than 
the  father,  and  the  females  of  a  family  are  more  likely  to  suffer 
than  the  males  (Gowers). 

The  female  is  rather  more  frequently  affected  with  epilepsy 
than  the  male  sex,  in  the  proportion  of  114  to  100  according 
to  Dr.  Gowers.  Females  are  attacked  with  hystero-epilepsy  in 
the  proportion  of  2  to  1  of  males. 

Age  is  an  important  predisposing  cause  of  epilepsy.  Out 
of  1,450  cases  analysed  by  Dr.  Gowers  the  disease  began  under 
ten  years  of  age  in  29  per  cent,  between  ten  and  twenty 
in  46  per  cent,  between  twenty  and  thirty  in  15  "7  per  cent, 
between  thirty  and  forty  in  6  per  cent,  between  forty  and 
fifty  in  2  per  cent,  between  fifty  and  sixty  in  1  per  cent,  and 
above  sixty  years  of  age  in  ^rd  per  cent.  The  proportion  in 
which  the  two  sexes  suffer  varies  at  different  periods  of  life. 
Speaking  broadly,  of  the  number  attacked  under  thirty  years 
of  age  the  males  exceed  the  females,  while  beyond  the  pro- 
portion is  reversed.  It  has  been  asserted  that  when  a  here- 
ditary tendency  exists  the  disease  begins  before  twenty  years 
of  age,  but  Dr.  Gowers  maintains  that  the  influence  continues 
until  a  late  period  of  life. 

Defective  nutrition  of  the  body  generally,  including  the 
nervous  system,  such  as  is  met  with  in  ansemia,  chlorosis,  scrofula, 
and  rickets,  appears  to  beget  a  certain  instability  of  the  nervous 
system  which  predisposes  to  the  production  of  epilepsy.  Chronic 
alcoholism  is  also  often  associated  with  epilepsy,  but  it  is 
difficult  to  determine  whethier  the  former  is  the  cause  of  the 
latter,  or  both  result  from  a  hereditary  taint. 

Of  the  exciting  causes  of  epilepsy,  profound  emotional  distur- 
bance, arising  from  fright,  grief,  and  anxiety,  is  the  most  frequent 
and  important.  The  first  attack  of  epilepsy  often  appears  after  a 
sudden  fright.  This  cause  is  most  frequently  in  operation  under 
twenty  years  of  age,  and  the  female  sex  is  especially  liable  to  be 
affected  by  it.  Epilepsy  is  sometimes  excited  in  apparently 
healthy  individuals  by  witnessing  another  in  convulsion. 
Eccentric  irritation  is  another  frequent  exciting  cause  of  epilepsy. 
Of  the  cases  which  date  their  origin  from  infancy,  the  first  fits 
occur  in  a  large  proportion  during  dentition.  It  must  be 
remembered   that  children  who  have  suffered  from  eclamptic 


EPILEPSY.  915 

attacks  during  deotition  frequently  develop  true  epilepsy  at 
puberty,  but  it  is  probable  that  there  exists  in  such  cases  a 
strong  predisposition  to  the  disease. 

The  influence  of  sexual  excess  in  the  production  of  epilepsy 
is  probably  over-estimated.  Women,  the  subjects  of  epilepsy, 
not  unfrequently  suffer  from  a  fit  during  the  menstrual  period, 
and  the  disease  may  be  caused  by  uterine  and  ovarian  derange- 
ments and  by  pregnancy.  Among  other  reputed  causes  of 
epilepsy  may  be  mentioned  diarrhoea,  dysentery,  overloading 
the  stomach,  irritation  of  the  intestinal  canal  from  the  presence 
of  worms,  the  passage  of  gall  stones,  over-exertion,  and  exposure 
to  cold. 

Epilepsy  is  also  liable  to  become  established  in  the  course  of 
or  during  convalescence  from  acute  febrile  diseases,  a  con- 
siderable proportion  of  such  cases  following  scarlet  fever,  In 
these  a  connection  between  the  eclampsia  of  scarlatinal  nephritis 
and  the  subsequent  recurrence  of  convulsions  can  only  occa- 
sionally be  traced  (Gowers).  Chronic  lead-poisoning  is  some- 
times attended  by  recurring  convulsions  like  those  of  epilepsy. 

Injuries  to  the  head  and  sunstroke  are  frequently  followed 
by  epilepsy.  Cases  in  which  the  skull  is  fractured  or  coarse 
structural  changes  are  set  up  in  the  brain  are  at  present  excluded 
from  consideration.  Injuries  to  nerve  trunks  are  liable  to  be 
followed  by  epilepsy,  and  the  first  seizure  usually  occurs  weeks, 
months,  or  even  years  after  the  injury.  The  convulsion  is 
generally  preceded  by  some  peculiar  sensation  proceeding  from 
the  region  of  the  affected  nerve. 

§  956.  Sy/nptoms. — The  symptoms  of  epilepsy  may  be 
divided  into  (1)  those  which  precede  the  paroxysm,  (2)  those 
occurring  during  the  paroxysm,  and  (3)  those  observed  in  the 
intervals  between  the  attacks. 

(1)  Premonitory  SymiJtoms. — The  premonitory  symptoms 
of  the  epileptic  attack  may  be  subdivided  into  remote  and 
immediate  warnings,  the  latter  forming  the  auroe  epilepticcB, 
The  remote  warnings  may  extend  over  hours  or  days  before 
the  occurrence  of  the- attack;  they  usually  consist  of  such 
symptoms  as  headache,  dizziness,  confusion  of  thought,  or  some 
mental  change,  the  patient  becoming  depressed  and  morose,  or 


916  EPILEPSY. 

excited,  lively,  and  irritable.  In  a  case  recently  under  my 
care  the  patient  stated  that  for  hours  before  an  attack  he 
became  sometimes  very  much  depressed  in  spirits  and  sus- 
picious that  his  friends  were  speaking  and  plotting  against  him, 
while  at  other  times  he  was  unaccountably  joyous.  He  then 
volunteered  the  statement :  "I  am  expecting  an  attack  to-day, 
for  instance,  I  feel  so  happy  and  joyous,  and  there  is  nothing 
in  my  circumstances  to  make  me  so,  as  I  have  just  lost  my 
situation  through  these  fits."  During  examination  his  right 
cheek  was  suffused  with  a  bright  red  blush  ;  while  the  left  one 
was,  as  his  face  had  hitherto  always  been  when  I  saw  him, 
remarkably  pale.  If  the  cortex  of  the  hemispheres  of  the  brain 
were  as  freely  supplied  with  blood  as  the  right  cheek,  this 
might  account  for  his  joyous  feelings. 

Aurce  Epilepticce. — Our  information  with  regard  to  the 
immediate  warning  of  the  epileptic  paroxysm  consists  of  the 
subsequent  account  which  the  patient  is  able  to  give  of  his 
feelings  before  loss  of  consciousness  is  complete.  In  more 
theoretical  language,  the  aura  is  the  mental  correlative  of 
the  commencing  molecular  change  in  the  brain,  which  is 
the  physical  cause  of  the  epileptic  attack.  Consciousness  is 
abolished  so  soon  that  there  is  no  aura  described  in  about  half 
the  cases. 

The  aura  may  be  (a)  motor,  (6)  sensory,  (c)  vaso-motor  and 
secretory,  or  (d)  psychical. 

(a)  Motor  Aurce. — It  is  not  always  easy  to  distinguish 
between  a  motor  and  a  sensory  aura.  In  epileptic  seizures, 
where  consciousness  is  retained  throughout  the  attack,  or  lost 
only  at  a  comparatively  late  period,  the  patient  is  often  able  to 
describe  the  convulsions  of  the  limbs  in  objective  language. 
He  may  be  able  to  tell  that  he  first  felt  the  thumb  dragged 
across  the  palm  and  the  fingers  flexed  on  the  thumb,  and  that 
he  had  then  to  hold  the  convulsed  hand  with  the  other  one  in 
order  to  arrest  its  movements. 

A  patient  of  my  own  was  in  the  habit  of  acting  before  the 
students  with  great  fidelity  the  phenomena  of  the  attack.  He 
first  produced  twitching  of  the  muscles  of  the  angle  of  the 
mouth,  then  rotated  his  head  and  eyes,  and  finally  flexed  his 
fingers,  and  shook  his  arm  to  show  how  the  convulsions  had 


I 


EPILEPSY.  917 

invaded  the  upper  extremity.  The  attack  in  this  case  was  due 
to  coarse  lesion  of  the  cortex  syphilitic  in  origin,  and  conscious- 
ness was  only  partially  suspended  towards  the  termination  of 
the  attack.  In  idiopathic  epilepsy,  on  the  other  hand,  con- 
sciousness becomes  confused  at  such  an  early  period  that  the 
patient  is  unable  to  describe  his  feelings  in  objective  language, 
although  he  may  still  do  so  in  subjective  language.  When,  for 
instance,  the  convulsion  begins  in  the  hand,  the  patient,  instead 
of  describing  the  thumb  as  being  drawn  into  the  palm,  says 
that  he  feels  a  dragging  sensation  in  the  thumb  or  a  feeling 
of  creeping,  or  numbness  in  the  hand,  which  gradually  passes 
up  the  arm.  The  sensation  begins  sometimes  in  the  muscles 
of  the  shoulder  and  passes  down  the  arm ;  but  these  cases  are 
probably  always  associated  with  a  coarse  lesion  in  the  brain. 
When  the  convulsion  begins  in  the  lower  extremity,  the  aura 
generally  begins  as  a  creeping  sensation  in  the  big  toe,  which 
passes  up  the  leg  and  may  extend  to  the  arm  before  uncon- 
sciousness supervenes. 

The  motor  aura  begins  not  unfrequently  in  the  side  of  the 
face,  and  is  generally  described  as  a  feeling  of  "  the  face  being 
drawn,"  or  it  may  begin  in  the  side  of  the  tongue,  and  be 
described  as  a  feeling  of  something  crawling.  The  tongue  is 
associated  in  its  actions  with  different  sets  of  muscles,  according 
as  it  is  engaged  in  articulation,  mastication,  or  deglutition,  and 
these  associated  movements  appear  to  be  sometimes  dimly 
represented  by  the  epileptic  aura.  In  a  case  mentioned  by  Dr. 
Gowers  tingling  in  the  tongue  was  associated  with  twitching  of 
the  lips,  in  another  with  a  sensation  of  lateral  movements  of  the 
jaw,  and  in  a  third  it  was  followed  by  a  feeling  of  sickness, 
succeeded  by  a  sensation  of  something  rising  in  the  throat  and 
then  by  palpitation  of  the  heart. 

The  aura  consists  sometimes  of  sudden  inability  to  speak — 
a  temporary  aphasia, — or  there  may  be  motor  aurse  referred 
to  the  eyeballs,  which  are  generally  described  in  subjective 
language.  The  patient,  for  instance,  never  says  that  the  attack 
began  by  a  squint,  but  states  that  he  suffered  from  double 
vision.  On  rare  occasions  the  patient  may  describe  that  his 
eyes  were  turned  in  a  particular  direction ;  but,  as  a  rule,  the 
rotation  of  the  eyeballs  is  felt  by  the  patient  as  a  displacement 


918  EPILEPSY. 

of  external  objects  in  the  opposite  direction,  and  he  conse- 
quently complains  of  things  whirling  round  him,  of  swimming 
in  the  head,  or  of  vertigo  and  sickness.  At  times  patients  see 
objects  recede  from  them  and  become  smaller  or  approach  them 
and  become  larger,  sensations  probably  depending  upon  varia- 
tions in  the  tension  of  the  muscles  of  accommodation.  One 
of  the  most  remarkable  features  presented  by  motor  aurse  is 
that,  as  a  rule,  all  of  them  begin  in  small  muscles,  such  as  those 
of  the  eyeballs,  tongue,  face,  and  hands.  These  muscles  are 
engaged  in  the  most  special  actions,  and  consequently  the  motor 
aurge  may  be  said  to  begin  in  the  more  special  and  to  pass  gra- 
dually to  the  more  general  actions.  Sometimes  the  aura  begins 
in  muscles  like  those  of  the  shoulder  engaged  in  general  actions, 
while  the  muscles  engaged  in  special  actions  are  secondarily 
involved.  Such  cases  are  probably  always  due  to  organic  disease 
of  the  brain,  the  lesion  being  situated  near  the  longitudinal 
fissure  and  away  from  the  special  centres  of  the  operculum. 
Sometimes  the  aura  may  occur  in  both  hands  or  both  legs 
simultaneously,  or  there  may  be  a  sensation  of  trembling  in  the 
muscles  of  the  back,  while  at  other  times  general  tremor  or 
jerking  of  the  muscles  is  complained  of. 

(6)  Sensory  Aurce. — The  sensory  aurse  may  be  referred  to 
any ,  of  the  centripetal  nerves  of  the  body,  namely,  those  of 
the  skin,  muscles,  and  bones,  the  nerves  of  special  sense,  and 
the  nerves  of  the  viscera.  As  already  remarked,  it  is  not 
always  easy  to  determine  whether  the  sensations  referred  by  the 
patients  to  the  extremities  are  due  in  any  particular  case  to  a 
discharge  from  a  sensory  or  a  motor  centre  in  connection  with 
the  part.  Dr.  Gowers  remarks  that  there  are  two  modes  in 
which  the  aura  extends  from  the  arm  to  the  leg,  the  one  by 
continuity,  the  sensation  passing  up  the  arm  and  down  the 
trunk  to  the  leg ;  and  the  other  by  separate  commencement  in 
the  muscles  of  the  lower  extremity.  The  same  is  also  true  with 
regard  to  the  method  of  invasion  from  the  lower  to  the  upper 
extremity.  In  the  continuous  method  of  invasion.  Dr.  Gowers 
believes  that  the  discharge  from  the  sensory  centre  takes  the 
lead,  while  in  the  discontinuous  mode  of  invasion  the  discharge 
of  the  motor  centre  is  primary.  The  sensory  aura  sometimes 
consists  of  a  feeling  of  general  heat  or  cold,  and  at  other  times 


EPILEPSY.  919 

is  distinctly  localised.  Besides  various  sensations,  as  tingling, 
numbness,  or  pain  in  the  extremities,  it  may  consist  of  head- 
ache, frontal,  vertical,  or  unilateral,  or  a  feeling  of  pressure  in 
the  head  (Gowers). 

AuroB  of  the  Special  Senses. — The  aurse  of  the  special  senses 
may  consist  of  undeveloped  sensations,  which  Hughlings- 
Jackson,  following  Spencer,  has  named  crude  sensations,  or  of 
more  elaborate  sensory  representations.  During  the  former 
the  discharge  is  limited  to  a  sensory  centre,  so  that  a  simple 
sensation  only  is  revived  ;  during  the  latter  the  molecular  dis- 
turbance extends  to  neighbouring  sensory  centres,  so  that  com- 
plicated perceptions  result. 

Visual  Auroe. — The  aura  sometimes  consists  of  sparks, 
flashes  of  light,  and  coloured  vision.  In  some  cases  the  fit 
begins  by  a  coloured  vision,  followed  by  spectral  faces,  the 
former  being  a  crude  sensation,  and  the  latter  revived  per- 
ceptions. Illusions  of  sight  are  not  uncommonly  observed.  In 
a  case  of  my  own  the  attack  is  ushered  in  by  the  patient  finding 
himself  surrounded  by  lions  and  tigers,  ready  to  spring  upon 
him.  In  some  cases  the  fit  is  preceded  by  a  vision  of  beautiful 
places,  but  disagreeable  objects  and  scenes  are  more  common. 
In  many  cases  the  attack  is  ushered  in  by  sudden  blindness  of 
one  or  both  eyes. 

Auditory  auroe  may  consist  at  times  of  hissing,  ringing,  or 
explosive  noises  ;  at  other  times  voices  are  heard,  or  the  patient 
hears  distinct  words  and  sentences.  The  patient  may  hear  a 
noise  in  the  ear  at  first,  and  this  be  followed  by  a  distinct 
vocal  utterance,  while  in  other  cases  music  is  heard.  At  times 
the  attack  is  ushered  in  by  a  sensation  of  unusual  stillness. 

Gustatory  aurm  consist  of  metallic  or  other  abnormal  sen- 
sations of  taste.  The  alteration  in  the  sense  of  taste  may 
sometimes  be  manifested  by  semi-voluntary  or  automatic 
movements.  In  a  case  mentioned  by  Dr.  Hughlings-Jackson 
the  patient  "  put  different  substances  into  his  mouth  ;  at  the 
seaside,  sand ;  at  school  he  drank  ink ;  in  the  country  he  bit 
pieces  of  butterflies ;  he  smacked  his  lips  in  the  attacks,  and 
his  brother  said  he  had  a  look  of  disgust." 

Olfactory  aurce  consist,  as  a  rule,  of  unpleasant  smells, 
generally  described  in  subjective  language,  and  only  occasionally 


920  EPILEPSY. 

in  objective  language.  Dr.  Hughlings- Jackson  mentions  the 
case  of  a  patient  who  held  his  nose  when  the  attack  began ; 
probably  in  this  case  there  was  an  objective  sensation  of  smell. 

In  glancing  over  the  different  sensory  aurse,  the  most  remark- 
able characteristic  presented  is  that  a  general  sensation,  as  a 
red  colour,  often  precedes  the  appearance  of  the  more  special 
sensations,  such  as  are  afforded  by  definite  images  of  persons 
and  things.  With  the  motor  aura  we  saw  that,  as  a  rule,  the 
special  precedes  the  general ;  but  it  would  appear  that  in  the 
sensory  aurse  the  general  precedes  the  special. 

These  facts  find  their  interpretation  in  inferences  already 
made  from  embryological  considerations ;  namely,  that  the 
special  movements  are  represented  in  the  motor  area  of  the 
cortex  of  the  brain  by  comparatively  small  and  young  cells 
situated  in  the  neighbourhood  of  the  vessels ;  while  the  special 
sensations  are  represented  in  the  sensory  area  of  the  cortex  by 
comparatively  large  and  old  cells  thrust  away  from  the  vessels 
by  the  growth  of  young  cells,  the  latter  of  which  represent  the 
general  sensations. 

Visceral  Aurce. — The  most  common  of  all  the  immediate 
warnings  of  epilepsy  are  sensations  referred  to  different  portions 
of  the  area  of  distribution  of  the  pneumogastric  nerve.  Of 
these  a  sensation  referred  to  the  pit  of  the  stomach,  named  the 
epigastric  aura,  is  by  far  the  most  frequent.  It  is  sometimes 
described  as  pain,  at  other  times  as  a  feeling  of  "coldness," 
"burning,"  or  as  a  vague,  indescribable  sensation.  The  painful 
epigastric  feeling  is  generally  fixed ;  while  the  vague  sensation 
ascends  to  the  throat  and  causes  a  feeling  of  choking,  or  to  the 
head,  when  immediate  loss  of  consciousness  ensues  (Gowers). 
In  some  cases  a  feeling  of  suffocation  constitutes  the  warning ; 
in  others  there  may  be  nausea  and  retching,  a  feeling  of  intense 
hunger,  or  palpitation  with  or  without  angina. 

(c)  Vaso-motor  and  Secretory  Aurce. — The  attacks  may  be 
ushered  in  by  a  sensation  of  coldness,  or  numbness  in  the  fingers 
and  toes,  and  the  affected  part  becomes  pale  and  cold  to  the 
touch.  At  other  times  spots  in  various  parts  of  the  body  assume 
a  red  colour,  and  become  the  seats  of  feelings  of  transient  heat. 
Faintness,  which  constitutes  a  frequent  aura,  may  probably 
sometimes  be  associated  with  sudden  dilatation  of  the  abdo- 
minal vessels. 


EPILEPSY.  921 

(d)  Psychical  Aurce. — The  immediate  warning  often  con- 
sists of  intense  horror  or  alarm,  and  the  patient  may  look 
startled,  guilty,  or  frightened.  In  other  cases  it  consists  of 
an  intellectual  perversion.  The  patient  feels  as  if  he  were 
suddenly  in  a  strange  country,  or  the  idea  suddenly  seizes  him 
that  an  object,  at  which  he  may  be  looking  and  which  he  has 
never  seen  before,  was  known  to  him  previously.  In  many 
cases  the  aura  is  what  Dr.  Hughlings-Jackson  has  named  "  a 
dreamy  state "  or  a  "  voluminous "  mental  condition.  This 
condition  is  similar  to  that  said  to  be  experienced  by  persons 
in  the  act  of  drowning,  during  which  all  the  past  events  of 
life  seem  to  crowd  upon  the  memory. 

Order  of  Succession  of  the  Phenomena  of  the  Aura. — 
This  subject  is  so  wide  that  it  can  only  be  briefly  indicated  here. 
We  have  already  seen  that  when  the  aura  is  motor,  and  the 
spasm  begins  in  the  muscles  of  the  head,  those  of  the  arm  are 
next  invaded  and  those  of  the  leg  last ;  when  the  spasm  begins 
in  the  muscles  of  the  hand  those  of  the  face  are  next  invaded 
and  those  of  the  leg  last,  and  when  the  spasm  begins  in  the 
muscles  of  the  leg  those  of  the  arm  are  next  invaded  and  those 
of  the  face  last.  The  order  in  which  the  convulsions  spread  in 
these  three  forms  of  onset  may  be  readily  explained  by  reference 
to  the  topographical  distribution  of  the  motor  centres  in  the 
cortex. 

An  undeveloped  or  crude  sensation  of  sight,  such  as  a  red 
light,  is  sometimes  followed  by  a  developed  perception,  such  as 
the  image  of  a  man  ;  a  confused  noise  may  be  succeeded  by 
strains  of  music  ;  a  subjective  sensation  of  smell  may  be  followed 
by  efforts  to  prevent  the  effluvia  gaining  admission  to  the 
olfactory  chambers,  showing  that  the  sensation  had  become 
objective.  It  would  appear  that  in  all  these  cases  the  discharge 
begins  in  the  sensory  centre,  and  as  it  spreads  it  involves  a 
portion  of  the  cortex,  in  which  connections  are  formed  with  other 
sensory  centres,  so  that  the  discharge  is  now  accompanied  by  a 
perception.  This  process  is,  however,  soon  arrested  by  the 
rapid  impairment  of  consciousness,  during  which  both  sensa- 
tions and  perceptions  become  fainter  and  soon  disappear.  A. 
visual  is  not  unfrequently  associated  with  an  auditory  aura, 
sometimes  the  one  and  sometimes  the  other  taking  the  pre- 


922  EPILEPSY. 

cedence.  The  associatioa  of  these  sensations  is  readily  ex- 
plained by  the  proximity  of  the  visual  and  auditory  centres  as 
determined  by  Ferrier.  In  some  cases  the  epigastric  aura  is 
followed  by  an  emotion  of  fear  or  of  anguish,  and  the  patient 
may  have  a  facial  expression  corresponding  to  it.  It  has  been 
suggested  by  Hughlings-Jackson  that  there  may  often  be  a 
determinate  relation  between  sensory  and  visceral  aurse,  and 
between  the  "  dreamy "  state  of  psychical  aurse,  and  post- 
epileptic actions;  but  little  or  no  progress  has  hitherto  been 
made  in  collecting  materials  to  decide  the  question. 

(2)  The  Epileptic  Paroxysm.  —  The  symptoms  of  the 
paroxysm  are  very  variable,  but  for  purposes  of  description 
they  may  be  divided  into  {a)  epilepsia  mitior,  or  le  petit  mat,  in 
which  there  is  impairment  or  abolition  of  consciousness,  but 
no  manifest  spasms;  (6)  epilepsia  gravior,  or  le  haut  mal, 
in  which  there  is  loss  of  consciousness  along  with  general  tonic 
and  clonic  convulsions ;  (c)  epileptiform  seizures,  in  which  pro- 
nounced spasms  are  present  in  half  the  body,  but  with  only 
slight  suspension  of  consciousness. 

(a)  Epilepsia  mitior,  or  le  petit  mal. — The  description  of 
the  minor  attacks  of  epilepsy  need  not  detain  us  long.  The 
attack  consists  of  momentary  confusion  of  thought,  or  transitory 
unconsciousness.  The  patient,  for  instance,  may  be  attacked 
while  speaking ;  he  becomes  suddenly  unconscious,  there  is  a 
pause  probably  in  the  middle  of  a  sentence,  but  in  a  few 
seconds  speech  is  resumed  at  the  point  where  it  was  inter- 
rupted and  the  sentence  is  finished.  At  times  the  attack  may 
consist  of  a  feeling  of  fainting,  along  with  confusion  of  mind. 
In  other  cases  there  is  momentary  vertigo,  slight  pallor  of  the 
face,  and  transitory  unconsciousness.  Indeed,  any  one  of  the 
numerous  aurse  just  described  may,  along  with  slight  confusion 
of  mind,  constitute  a  minor  attack  of  epilepsy.  Many  of  the 
sensations  described  as  immediate  warnings  may  be  experienced 
in  the  absence  of  epilepsy;  but  if  the  sensation  recur  at 
periodical  intervals,  and  be  attended  by  some  confusion  of 
thought,  the  occurrence  of  genuine  epilepsy  may  be  suspected, 
although  a  visual  sensation,  along  with  some  confusion  of 
thought,  often  precedes  an  attack  of  migraine.     If  there  be 


EPILEPSY.  923 

involuntary  discharge  of  urine  or  faeces  during  the  attack  the 
affection  is  undoubtedly  epileptic. 

In  many  of  these  slighter  attacks  loss  of  consciousness  is 
accompanied  by  minor  degrees  of  muscular  spasm.  At  the 
onset  of  the  attacks  the  countenance  becomes  ghastly  pale,  the 
pupils  contracted,  and  the  eyes  fixed  and  staring,  or  there  may 
be  slight  strabismus  or  drawing  of  the  mouth,  while  in  other 
cases  there  may  be  partial  rotation  of  the  head  and  eyes,  chew- 
ing movements,  or  rolling  about  of  the  tongue.  There  may  be 
again  momentary  rigidity  or  slight  tremor  of  all  the  muscles  of 
the  body,  while  transitory  arrest  of  respiration  is  not  uncommon. 
Sometimes  the  patient  utters  a  shriek,  reels,  or  walks  hxirriedly 
round  the  room,  and  then  recovers.  At  times  the  unconscious- 
ness may  last  for  a  considerable  period,  but  the  patient  may  go 
on  with  the  work  in  which  he  was  engaged  as  if  he  were  con- 
scious. In  a  case  mentioned  by  Trousseau  the  patient  continued 
to  play  the  violin  with  accuracy  during  short  periods  of  uncon- 
sciousnesss.  It  must  be  remembered  that  the  slighter  attacks 
of  epilepsy  are  liable  to  be  followed  by  the  condition  named 
"  epileptic  mania,"  to  be  subsequently  described. 

(6)  Epilepsia  gravior,  or  le  haut  mal. — The  epileptic 
paroxysm  may,  for  the  purposes  of  description,  be  divided 
into  three  stages.  The  first  is  characterised  by  loss  of  conscious- 
ness with  tonic  spasm ;  the  second,  by  loss  of  consciousness 
with  clonic  spasm ;  and  the  third,  by  cessation  of  the  spasm 
and  gradual  restoration  to  consciousness.  A  fourth  or  after 
stage  may  be  added. 

(i.)  The  First  Stage. — The  true  epileptic  attack  is  ushered 
in  by  three  prominent  symptoms  occurring  simultaneously. 
These  are  loss  of  consciousness,  sudden  falling,  and  great  pallor 
of  the  face,  while  a  fourth  symptom  is  often  present  in  the 
form  of  a  loud  and  piercing  cry.  The  loss  of  consciousness  is 
sudden  and  complete,  every  form  of  s.ensibility  and  mental 
operation  being  completely  abolished,  although  certain  reflex 
actions  are  retained  (Romberg).  The  patient  often  falls,  as  if 
struck  by  lightning,  either  forwards  on  his  face,  backwards  on 
his  occiput,  or  latterly,  and  so  instantaneously  that  he  has  no 
time  to  select  a  place  or  attitude,  and  may  consequently  fall 
into  fire,  water,  or  from  a  height.     At  other  times  the  patient 


924  EPILEPSY. 

has  sufficient  warning  of  the  impending  attack  to  enable  him  to 
sit  or  lie  down.  Pallor  of  the  face  is  probably  always  present 
at  the  beginning  of  the  attack,  although  the  symptom  is  some- 
times so  transient  that  it  may  pass  unobserved. 

The  epileptic  cry  which  the  patient  often  utters  immediately 
before  or  during  the  fall  is  loud  and  piercing,  and  alarms, 
according  to  Romberg,  both  man  and  animals.  When  the 
patient  falls  to  the  ground  he  remains  for  a  period  of  from  two 
to  forty  seconds  in  a  rigid  condition,  caused  by  a  tonic,  although 
unequal  contraction,  of  all  the  muscles  of  the  body.  Various  dis- 
tortions are  thus  produced  ;  there  is  conjugate  deviation  of  the 
eyes,  with  rotation  of  the  head  and  neck ;  the  pupils  are  dilated 
and  insensible  to  light ;  the  countenance  is  variously  altered ; 
the  jaws  are  firmly  closed,  and  the  tongue  may  be  severely 
bitten ;  there  is  opisthotonos ;  and  the  different  segments  of 
the  lower  extremities  are  extended  upon  one  another  and 
upon  the  trunk,  the  foot  being  rotated  inwards  and  the  toes 
widely  separated ;  the  segments  of  the  upper  extremities  again 
are  flexed  upon  one  another,  the  thumb  being  bent  into  the 
palm,  the  fingers  closed,  and  the  hand  pronated ;  and  the  forearm 
is  flexed  or  sometimes  extended  upon  the  arm.  The  respiratory 
muscles  are  in  a  state  of  tonic  spasm,  and  the  breathing  is 
arrested.  The  hideous  cry  uttered  as  the  patient  falls  is  pro- 
bably produced  by  spasm  of  the  expiratory  muscles  with  closed 
glottis.  The  pallor  of  the  face  is  soon  replaced  by  a  dull  red  or 
dusky  hue,  and  the  veins  of  the  head  and  neck  become  greatly 
distended,  the  carotids  throb  violently,  and  the  action  of  the 
heart  is  forcible,  although  the  pulse  is  small  or  imperceptible  at 
the  wrist. 

(ii.)  The  Second  Period. — After  a  variable  period  of  from  two 
to  forty  seconds,  the  tonic  gives  place  to  clonic  spasms,  which  are 
usually  more  pronounced  on  one  side  of  the  body.  The  muscles 
of  the  face,  tongue,  pharynx,  and  larynx  are  usually  first  affected 
by  clonic  spasm,  and  those  of  the  trunk  and  extremities  are 
afterwards  invaded. 

The  patient  now  presents  a  hideous  appearance,  the  head  is 
alternately  drawn  laterally,  or  forwards  and  backwards ;  the 
eyeballs  are  convulsively  rotated  in  various  directions,  but 
rotation  in  an  upward  and  outward  direction  predominates,  so 


\ 


EPILEPSY.  925 

that  the  pupils  are  hidden,  and  only  the  whites  of  the  eyes  are 
visible  under  the  blinking  half-closed  lids ;  the  face  is  variously 
distorted,  and  the  convulsive  closure  of  the  jaws  is  often  so 
violent  that  teeth  are  broken  and  the  tongue  severely  bitten, 
while  the  blood  from  the  wound,  mixing  with  the  saliva,  oozes 
through  the  clenched  teeth  as  a  sanguineous  froth.  The  trunk 
and  limbs  are  variously  thrown  about,  and  the  contents  of  the 
bladder,  rectum,  or  vesiculse  seminales  may  be  evacuated. 

The  venous  hypersemia  reaches  its  maximum  just  as  the 
clonic  spasms  are  beginning  to  abate  in  severity  ;  and  the  skin  is 
bathed  in  sweat,  which  in  some  cases  has  a  foetid  odour.  The 
heart  beats  tumultuously  ;  the  carotids  throb  ;  and  the  pulse,  if 
it  can  be  felt,  is  fuller  and  more  laboured  than  during  the 
period  of  tetanic  contractions.  The  pupils  are  alternately 
contracted  and  dilated,  and  are  said  to  be  slightly  sensible  to 
light.  This  stage  may  last  from  a  few  seconds  to  five  or  ten 
minutes,  the  average  duration  being  from  two  to  three 
minutes. 

(iii.)  The  Third  Stage. — During  the  third  stage  there  is  a 
gradual  return  to  consciousness  and  voluntary  power.  The 
convulsions  either  cease  suddenly  or  wear  off  gradually,  the 
period  of  transition  being  marked  by  partial  jerkings  of  some 
muscular  groups,  or  by  a  diffused  tremor  of  the  body. 

General  muscular  relaxation  is  now  established,  but  coma 
persists  for  a  short  time  longer.  The  patient  soon  attempts 
to  change  his  position  ;  he  opens  his  eyes  and  looks  around  him 
with  a  bewildered  expression,  and  perhaps  attempts  to  speak. 

The  respiratory  movements  have  become  more  natural  in 
rhythm,  although  they  are  still  somewhat  irregular ;  the  pupils 
are  contracted ;  the  pulse  is  variable,  but  generally  full  and 
quieter  than  during  the  previous  stage;  the  conjunctivae  are 
injected ;  petechise  are  often  observed  on  the  eyelids,  forehead, 
and  temples ;  and  the  patient  is  exhausted  and  disposed  to 
sleep. 

The  attack  is  often  followed  by  vomiting,  and  a  large  quan- 
tity of  pale  urine  is  often  passed.  The  temperature  of  the  body 
appears  to  be  normal  after  single  attacks  of  epilepsy. 

(iv.)  The  Fourth  or  After-Stage. — The  after-symptoms  of 
epilepsy  differ  greatly  in  duration,  severity,  and  nature.     The 


926  EPILEPSY, 

patient  recovers  occasionally  in  about  a  quarter  of  an  hour  after 
the  attack,  and  resumes  his  previous  occupation  ;  but,  as  a  rule, 
recovery  is  delayed  for  a  much  longer  period.  He  suffers  from 
lassitude  and  stupor,  from  which  he  is  aroused  with  difficulty, 
and,  if  awakened,  he  is  peevish  and  irritable,  while  the  general 
muscular  relaxation  is  occasionally  interrupted  by  momentary 
clonic  spasms  or  fibrillary  contractions.  The  average  duration 
of  the  stupor  is  about  an  hour  when  the  attack  occurs  during 
the  day ;  but  when  it  occurs  in  the  evening  it  passes  insensibly 
into  the  ordinary  nocturnal  sleep. 

Complications. — Various  mental  disturbances  are  by  far  the 
most  important  of  the  complications  of  epilepsy.  The  patient 
sometimes  exhibits  marked  mental  derangement  immediately 
before  as  well  as  after  the  paroxysm,  and  a  maniacal  condition 
constitutes  sometimes  the  principal  feature  of  the  attack.  A 
person  the  subject  of  epileptic  vertigo  may  continue  for  some 
seconds,  minutes,  or  even  hours  in  a  dull,  half  stupid  condition. 
He  may  mutter  a  few  incoherent  words,  or  some  lewd  expression, 
no  matter  how  foreign  to  his  habit;  he  may  unbutton  his 
clothes  and  expose  his  person,  urinate  in  a  public  assembly, 
exhibit  himself  naked  to  his  domestics,  or  even  walk  in  public 
naked  unless  prevented,  and  on  recovery  he  has  only  the 
vaguest  recollection  of  what  has  occurred.  These,  however,  are 
only  a  few  of  the  minor  actions  which  may  be  done  by  indivi- 
duals subject  to  epileptic  vertigo  immediately  after  the  attack. 
The  most  motiveless  and  atrocious  crimes  are  sometimes  com- 
mitted in  this  condition,  so  that  some  medical  jurists  are  of 
opinion  that  no  epileptic  is  responsible  for  his  actions.  Epileptics 
sometimes  have  a  warning  of  the  approaching  maniacal  state, 
so  that  they  can  warn  their  friends  to  protect  themselves ; 
but  generally  the  seizure  is  more  or  less  sudden.  There  is 
every  variety  of  intermediate  form  between  the  milder  and 
severer  cases.  Reynolds  says  that  epileptic  mania  occurs  in 
about  one-tenth  of  all  cases  of  epilepsy,  including  the  minor 
attacks  of  epileptic  vertigo  ;  having  occurred  in  the  case  of  any 
one  individual,  it  is  apt  to  appear  again,  especially  when  several 
fits  have  followed  in  rapid  succession. 

Epileptic  delirium  is  not  always  furious  and  dangerous.     It 
may  appear  in  the  form  of  preternatural  gaiety  or  illusions 


EPILEPSY.  927 

of  the  senses  before  the  attack,  or  during  the  intervals. 
Meningitis  has  been  known  to  follow  epileptic  paroxysms  ;  but 
it  is  generally  the  result  of  an  injury  inflicted  by  the  fall,  and 
both  apoplexy  and  permanent  paralysis  are  rare  complications 
of  idiopathic  epilepsy.  Idiocy  and  epilepsy  are  not  unfrequently 
associated,  in  which  case  the  former  disease  is  generally  con- 
genital. 

Attacks  of  Hystero-epilepsy. — Hystero-epileptic  attacks  are 
not  often  seen  in  this  country  in  the  classical  form  described 
by  French  authors.  The  patient  in  the  intervals  suffers  from 
various  hysterical  symptoms,  the  most  usual  of  which  are 
complete  or  incomplete  hysterical  hemiansesthesia,  and  ovarian 
hypergesthesia.  The  paroxysm  is  always  preceded  by  an  aura, 
consisting  of  a  sensation  proceeding  from  the  region  of  the 
hypergesthetic  ovary  towards  the  epigastrium,  and  ascending 
to  the  throat  and  finally  to  the  head,  when  the  patient  utters 
a  loud  shriek  and  falls  insensible  to  the  ground.  All  the 
muscles  of  the  body  now  become  the  subjects  of  tonic  spasm; 
the  head  is  retracted,  and  the  body  and  limbs  are  arched  back- 
wards and  rigid ;  the  respirations  are  stertorous  and  infrequent ; 
and  foam,  sometimes  blood-stained  on  account  of  the  tongue 
having  being  bitten,  generally  issues  from  the  mouth.  The 
tonic  stage  is  followed  by  a  few  clonic  convulsions,  but  these 
soon  cease,  and  a  state  characterised  by  general  muscular 
relaxation,  stertorous  respiration,  and  coma  terminates  the 
portion  of  the  attack  resembling  the  epileptic  paroxysm. 

The  second  stage,  or  what  the  French  call  the  "phase  des 
grands  mouvetnents,"  now  makes  its  appearance.  It  is  charac- 
terised by  violent  contortions  of  the  body,  and  gesticulations 
having  a  purposive  character.  There  is  opisthotonos,  or  the 
body  IS  bent  forwards  or  laterally ;  while  at  other  times  it  is 
maintained  in  a  rigid  position,  with  the  lower  extremities 
extended  and  the  upper  stretched  out. 

The  third  stage,  or  stage  of  emotional  attitudes  (phase  des 
attitudes  passionelles),  now  appears,  and  during  its  continuance 
the  patient  assumes  in  rapid  succession  attitudes  and  gestures 
expressive  of  various  emotions.  The  first  attitude  assumed,  by 
the  patient  is  usually  a  threatening  one ;  she  raises  herself  in 


928  EPILEPSY. 

a  half  sitting  posture,  the  brows  frown,  the  fists  are  clenched, 
and  the  face  presents  an  augry  and  menacing  expression  ;  this 
attitude,  however,  soon  gives  place  to  an  expression  of  abject 
fear,  which  in  its  turn  makes  room  for  a  look  of  intense  happi- 
ness and  beatitude.  But  the  expression  of  beatitude  is  also 
fleeting  in  character,  and  is  succeeded  by  one  of  intense  volup- 
tuousness, followed  by  gestures  which  lead  to  this  stage  being 
called  the  phase  of  lubricity.  Terror  now  seizes  the  patient, 
she  sees  rats  and  other  odious  animals  that  evoke  from  her 
passionate  exclamations  of  dread  and  disgust,  and  this  is 
followed  by  a  stage  in  which  she  appears  to  be  labouring  under 
the  idea  that  she  has  committed  a  great  offence,  and  sues  for 
mercy.  The  patient  now  hears  strains  of  music,  she  looks 
pleased,  and  may  join  in  humming  the  tune  ;  but  her  singing  is 
soon  followed  by  weeping,  broken  by  reproaches  addressed  to 
her  parents  as  the  cause  of  her  misery.  This  last  phase  con- 
stitutes the  stage  of  recovery,  but  hallucinations  may  persist 
for  some  time.  The  patient  can  always  describe  subsequently 
the  hallucinations  to  which  she  was  subject,  and  each  of  the 
attitudes  is  found  to  have  corresponded  to  a  hallucination. 

An  attack  of  hystero-epilepsy  may  be  provoked  at  any  time 
by  various  manipulations,  such  as  "suddenly  'gripping'  the 
skin  of  the  breast  on  both  sides  on  a  level  with  the  fifth  rib, 
and  midway  between  the  anterior  and  posterior  boundaries 
of  the  axillae."*  An  attack  is  also  readily  induced  by  pinching 
a  fold  of  the  skin  of  the  sub-inguinal  region,  or  by  slight  pres- 
sure on  the  region  of  the  hypersesthetic  ovary.  Sudden  and 
firm  pressure  exerted  on  the  affected  ovary,  however,  instantly 
arrests  the  paroxysm  at  any  stage.  When  such  compression  of 
the  ovary  is  made,  the  patient's  mouth  opens  widely,  the  tongue 
is  spasmodically  protruded,  and  the  convulsions  cease. 

The  phenomena  presented-  by  attacks  of  hystero-epilepsy  in 
this  country  are  too  variable  to  be  comprised  under  one  general 
description.  In  some  cases  there  is  a  condition  of  emprostho- 
tonos,  instead  of  opisthotonos,  during  the  second  stage  of  the 
attack,  this  form  being  very  liable  to  occur  in  boys.  In  other 
cases  the  legs  are  alternately  flexed  and  extended,  and  the 

*  An  Account  of  the  Phenomena  of  Hystero-Epilepsy,  by  Arthur  Gamgee, 
M.D.,  r.R.S.,  "British  Medical  Journal,"  vol.  ii.,  1878. 


EPILEPSY,  929 

patient,  who  lies  on  her  back,  may  be  propelled  from  one  end 
of  the  room  to  the  other.  In  still  other  cases  the  attack 
consists  of  great  difficulty  of  breathing  caused  by  intense  respi- 
ratory spasm  (Gowers). 

(c)  Epileptiform  Seizures. — This  form  of  epilepsy  was  first 
described  by  Bravais,  but  its  pathology  was  fully  investigated 
by  Haghlings-Jackson,  and  it  is  consequently  named  "  Jack- 
sonian  Epilepsy."  In  it  the  convulsions  are  partial,  being 
limited  to  one  half  of  the  body,  and  consciousness  is  either 
retained  throughout  the  attack,  or  lost  only  at  a  comparatively 
late  period.  The  fits  are  accompanied  or  followed  by  paresis  of 
the  convulsed  limbs.  These  seizures  are  caused  by  coarse 
disease  situated  near  the  cortex  of  the  brain,  the  most  common 
lesion  being  a  gumma.  The  convulsions  which  supervene  upon 
the  spastic  hemiplegia  of  childhood  (unilateral  atrophy  of  the 
brain)  are  at  first  partial,  but  after  a  time  become  general.  An 
interesting  case  of  epilepsy  in  a  girl  aged  6|  years  is  recorded 
by  Dr.  Sturge,  in  which  the  convulsions,  which  began  when  the 
patient  was  6  months  old,  were  at  first  limited  to  the  left  half 
of  the  body,  and  always  began  in  the  left  hand  after  they  had 
become  general.  The  left  half  of  the  body  was  observed  to  be 
weak  for  some  time  after  each  partial  convulsion.  The  patient 
was  born  with  an  extensive  "  mother's  mark  "  on  the  right  side 
of  the  head  and  face ;  it  extended  to  the  mucous  membrane  of 
the  tongue,  uvula,  and  pharynx  on  the  same  side,  the  sclerotic 
coat,  retina,  and  choroid  of  the  right  eye  being  also  implicated. 
Dr.  Sturge  makes  the  very  probable  conjecture  that  the  attacks 
were  due  to  a  "  port  wine  mark  "  on  the  surface  of  the  right 
hemisphere  of  the  brain  similar  to  that  on  the  face. 

(3)  The  Interparoxysmal  Condition. — The  condition  which 
exists  during  the  interval  between  the  epileptic  attacks  was 
first  fully  examined  by  Dr.  Russell  Reynolds,  and  deserves 
careful  attention.  The  most  important  phenomena  observed 
are  those  which  belong  to  the  mental  condition  of  the  patients. 
In  a  considerable  number  of  cases  no  mental  disturbance  or 
weakness  whatever  can  be  discovered  in  the  condition  of  the 
patient  between  the  attacks,  and  occasionally  individuals 
possessed  of  high  intellectual  powers  are  the  subjects  of 
HHH 


930  EPILEPSY. 

epilepsy.  The  classical  cases  of  Julius  Csesar  and  Napoleon, 
both  of  whom  suffered  from  the  disease,  may  be  cited  as 
examples. 

Slight  impairment  of  memory,  especially  with  regard  to  recent 
events,  while  the  remembrance  of  remote  occurrences  is  intact, 
is  the  most  common  and  generally  the  first  mental  change. 
The  next  grade  of  mental  impairment  declares  itself  in  a  certain 
amount  of  mental  dulness  and  want  of  apprehension ;  while  a 
still  lower  degradation  is  manifested  by  confusion  of  ideas, 
general  want  of  comprehension,  and  deficiency  in  intellectual 
activity,  associated  with  a  stupid  and  vacant  expression.  The 
moral  nature  is  almost  invariably  perverted,  the  patients  being 
gloomy,  irritable,  and  distrustful. 

One  or  other  of  these  minor  mental  defects  may  continue 
to  exist  without  any  appreciable  change  during  a  series  of  years  ; 
but  at  other  times  the  mental  change,  beginning  with  minor 
degrees  of  impairment,  passes  through  lower  and  lower  depths 
of  deterioration  until  the  patient  arrives  at  a  condition  of  com- 
plete imbecility. 

The  conditions  which  determine  mental  failure  in  epileptics 
have  been  carefully  examined  by  Dr.  Russell  Reynolds ;  the 
following  are  the  most  important  conclusions  at  which  he 
arrived.  Hereditary  taint  is  without  influence,  and  the  same 
may  be  said  of  the  duration  of  the  disease,  the  state  of 
the  general  health,  the  number  of  attacks,  the  nature  of  the 
exciting  cause,  and  the  severity  of  the  paroxysm  when  judged 
by  the  duration  of  the  subsequent  coma.  Frequency  of  recur- 
rence of  the  seizures  exerts  a  certain  amount  of  influence  in  the 
production  of  mental  impairment,  yet  there  is  no  constant  con- 
nection between  the  two  phenomena.  Mental  impairment  is, 
according  to  Reynolds,  more  frequently  associated  with  minor 
than  with  major  attacks  of  epilepsy,  and  appears  to  be  not 
in  direct  but  rather  in  inverse  proportion  to  the  degree  of 
muscular  manifestation. 

Motor  Manifestations. — Some  motor  disturbances  occur  in 
the  intervals  between  the  attacks  in  the  majority  of  instances. 
These  appear  in  the  form  of  simple  muscular  trembling,  or 
there  may  be  clonic  or  tonic  spasms  in  single  groups  of  muscles. 
Clonic  spasm  is  the  most  frequent,  and  may  occur  in  either  of 


I 


EPILEPSY.  931 

two  forms.  There  may  be  more  or  less  constant  choreiform 
movement,  which  continues  during  sleep,  but  is  exaggerated 
during  waking  hours,  as  in  the  spastic  hemiplegia  of  childhood ; 
or  there  may  be  violent  spasmodic  shakings  of  the  limbs  or  of 
the  trunk,  occurring  at  irregular  intervals,  and  with  special 
frequency  just  as  the  patient  is  falling  asleep;  the  muscular 
jerking  is  sometimes  so  sudden  and  violent  that  the  patient  is 
thrown  out  of  bed ;  or,  if  standing,  he  may  be  thrown  down. 
Cramp  or  tonic  contraction  is  comparatively  rare. 

Sensory  Manifestations. — The  sensory  disturbances  are  by 
no  means  so  constant  and  important  during  the  intervals  as 
the  motor.  Headache  and  vertigo  are  the  two  symptoms  most 
frequently  complained  of,  and  the  latter  must  sometimes  be 
regarded  in  the  light  of  an  abortive  attack. 

State  of  the  General  Health. — There  is  no  constant  relation 
between  epilepsy  and  any  particular  state  of  health.  It  is  no 
doubt  sometimes  associated  with  a  feeble  state  of  the  general 
health,  but  it  is  much  more  frequent  to  find  epilepsy  in  those 
who  are  in  other  respects  quite  healthy,  and  some  epileptics  are 
remarkable  for  their  Herculean  frame  and  strength.  The  most 
frequent  change  which  Dr.  Reynolds  observed  in  epileptics 
was  subnormal  temperature,  and  the  least  frequent  impaired 
nutrition. 

Relations  between  the  Symptoms  of  Epilepsy. 

(a)  Forms  of  Attack. — Hereditary  taint  appears  to  exert 
an  influence  in  predisposing  to  the  severer  form  of  epilepsy, 
although  milder  attacks  may  be  associated  with  the  severer  in 
the  cases  where  there  is  a  frequent  recurrence  of  the  latter. 
When  epilepsy  is  developed  at  an  early  age,  there  is  a  some- 
what increased  proclivity  to  the  attack  in  its  milder  form.  When 
epilepsy  becomes  developed  in  consequence  of  a  peripheral 
source  of  irritation,  an  interval  of  weeks  or  even  months  elapses 
between  the  time  the  injury  is  inflicted  and  the  first  seizure. 
During  this  period  painful  sensations  may  be  felt,  or  there 
may  be  clonic  or  tonic  spasms  in  the  area  of  distribution  of  the 
affected  nerve,  or  the  two  conditions  may  be  combined.  After 
a  time  spasmodic  seizures  appear  with  loss  of  consciousness ; 
they  are  ushered  in  either  by  a  sensory,  motor,  or  vaso-motor 


932  EPILEPSY. 

aura,  which  is  always  of  the  same  kind  in  the  same  individual, 
and  begins  in  the  region  of  the  injured  nerve.  When  a 
cicatrix  is  found  in  the  course  of  the  affected  nerve,  an  attack 
may  occasionally  be  produced  by  pressing  upon  it.  Dr.  Ogle 
reports  a  case  in  which  a  seizure  could  be  produced  by  touching 
the  upper  extremity,  but  the  epileptogenous  zone  is  not  usually 
distinctly  marked. 

(bj  Frequency  of  Attacks. — The  paroxysms  as  a  rule  recur 
very  irregularly,  but  Reynolds  thinks  that  frequently  "  the 
recurrence  of  attacks  has  some  relation  to  time,  as  marked  by 
its  natural  division  into  days,  and  periods  of  seven  days,  and 
multiples  of  seven  days.  Thus  a  large  number  of  epileptics 
have  their  seizures  every  day,  every  two  weeks,  three  weeks,  and 
four  weeks,  while  only  a  much  smaller  number  suffer  at  such 
irregular  intervals  as  cannot  be  thus  expressed." 

Sometimes  the  mode  of  recurrence  is  what  has  been  termed 
"  serial."  The  patient  suffers  from  two  or  more  attacks  in  a  day, 
usually  within  twelve  hours,  and  then  there  is  a  free  interval  of 
from  one  to  several  weeks.  This  mode  of  recurrence  is  more 
frequent  in  the  female  than  in  the  male  sex. 

The  frequency  of  the  paroxysms  varies  within  wide  limits, 
some  patients  only  having  one  seizure  a  year,  others  having 
thousands  ;  but  Reynolds  states  that  half  the  cases  are  found  to 
have  a  rate  of  recurrence  ranging  from  one  attack  in  fourteen 
to  one  in  thirty  days.  A  high  rate  of  frequency  is  generally 
observed  in  those  who  are  in  more  or  less  robust  health;  and 
a  low  rate  of  frequency  in  those  whose  general  condition  has 
undergone  marked  deterioration.  Early  commencement  of  epi- 
lepsy is  commonly,  but  not  always,  associated  with  a  high  rate 
of  frequency  of  recurrence. 

The  groups  of  attacks  may  be  composed  of  from  four  to  a 
hundred  or  more  single  seizures  in  twenty-four  hours.  This 
condition  may  extend  over  a  much  longer  period,  and  Delasiauve 
saw  in  a  boy  of  fifteen,  within  one  month,  a  "collective  seizure" 
which  was  composed  of  2,500  "fragmentary  seizures."  The 
French  have  designated  this  condition  dat  de  mal  4pileptique 
(^status  epilepticwsj,  and  Bourneville  has  recently  drawn  atten- 
tion to  the  great  increase  of  temperature  which  characterises 
the  condition.     The  patients  lie   in  profound   coma,  and  the 


EPILEPSY.  933 

temperature  may  rise  to  107'6°  F.,  and  still  higher  in  fatal  cases. 
In  favourable  cases  the  temperature  gradually  falls,  but  in  other 
cases  a  subsequent  rise  takes  place,  coma  becomes  profound, 
and  the  patient  dies,  often  with  symptoms  of  collapse  associated 
with  the  formation  of  acute  "  bed-sores." 

It  is  well  to  remember  that  the  attacks  frequently  occur  at 
night,  and  especially  is  epilepsy  apt  to  commence  in  this  way. 
Our  attention  should  be  directed  especially  to  this  fact  if  a 
previously  healthy  patient  complain  sometimes  on  waking  in 
the  morning  of  such  symptoms  as  depression,  stupidity,  and 
headache ;  the  surmise  of  epilepsy  will  be  rendered  certain  if 
in  addition  there  have  been  involuntary  discharge  of  urine  or 
faeces,  if  the  tongue  be  bitten,  or  if  small  haemorrhages  into  the 
skin  be  fouud. 

§  957.  Course,  Duration,  and  Terminations. — Epilepsy  is 
essentially  chronic  and  may  last  for  years,  and,  although  death 
occasionally  occurs  during  a  paroxysm,  this  is  exceedingly 
rare.  The  course  of  the  disease  does  not  appear  to  be  much 
influenced  by  surrounding  circumstances,  and  not  nearly  so 
much  as  might  be  anticipated  by  the  health  of  the  patient  in 
other  respects.  The  abuse  of  alcoholic  liquors  aggravates  the 
attacks,  and  even  drinking  a  moderate  allowance  of  beer  or 
wine  appears  to  act  unfavourably  on  the  course  of  the  disease. 
Excess  in  eating  and  drinking  tea  and  coffee  also  appears  to 
aggravate  the  disease.  The  influence  which  a  moderate  indul- 
gence of  venery  exerts  upon  the  course  of  epilepsy  is  not  well 
determined.  Many  instances  are  known  where  a  paroxysm 
came  on  during  coitus,  and  venereal  excess  doubtless  aggravates 
the  disease. 

During  the  course  of  acute  diseases  the  epileptic  paroxysms 
usually  cease,  but  generally  return  during  convalescence;  a 
similar  effect  is  sometimes  produced  by  external  injuries. 
Chronic  diseases  act  in  different  ways,  sometimes  mitigating,  at 
other  times  aggravating  the  paroxysms,  and  at  still  other  times 
not  appearing  to  exert  any  influence  on  the  course  of  the  disease. 

Mental  affections  of  one  kind  or  another  are  frequently 
associated  with  epilepsy,  but  Reynolds  has  shown  that  their 
concomitance  is  not  nearly  so  frequent  as  was  at  one  time 


934  EPILEPSY, 

supposed.  It  appears  that  some  mental  affection  is  found 
associated  with  epilepsy  in  about  one-third  of  all  cases,  and 
especially  in  those  cases  where  the  paroxysms  follow  each  other 
in  unusually  rapid  succession.  In  some  of  those  cases  there  is 
every  reason  to  conclude  that  the  mental  affection  and  epileptic 
attacks  are  joint  effects  of  one  common  lesion. 

§  958.  Morbid  Anatomy. — Post-mortem  examination  has 
revealed  the  most  various  anatomical  changes  after  death  from 
epilepsy  in  almost  every  organ  of  the  body,  but  none  of  these  are 
constant  and  some  are  quite  exceptional.  Various  irregularities 
have  been  found  in  the  structure  of  the  skull,  especially  if  the 
disease  be  hereditary  or  have  existed  from  an  early  age.  The 
bones  of  the  skull  may  be  thickened,  and  there  may  be  exostoses 
on  the  internal  surface  of  the  skull,  or  contraction  of  the  carotid 
foramen  or  of  the  foramen  magnum. 

The  meninges  of  the  brain  are  sometimes  opaque,  thickened, 
or  distorted,  especially  if  osteosclerosis  exist  at  the  same  time. 
Various  statements  have  been  made  with  respect  to  the  weight 
of  the  brain,  Echeverria  considering  that  the  brain  is  increased 
in  weight,  while  Meynert  found  a  decrease  in  weight  in  epileptic 
insanity.  Asymmetry  of  the  cerebral  hemispheres  has  been 
observed  pretty  frequently.  Meynert  also  found  a  difference 
between  the  two  hippocami  majores,  caused  by  progressive 
atrophy,  associated  with  cartilaginous  hardness  of  one  of  them, 
but  he  regarded  this  condition  not  so  much  a  cause  as  a  result 
of  epilepsy.  An  abnormal  distribution  of  the  grey  substance  of 
the  cerebrum  and  cerebellum  has  been  met  with  ;  but  this 
condition  has  also  been  found  apart  from  epilepsy.  Disease 
of  the  pituitary  body  is  sometimes  associated  with  epilepsy.  In 
chronic  cases  microscopical  changes  have  frequently  been  found 
by  Schroeder  van  der  Kolk,  Echeverria,  and  L.  Meyer  in  the 
medulla  oblongata,  and  also  in  other  parts  of  the  brain  and 
uppermost  part  of  the  cervical  region  of  the  cord.  The  changes 
observed  consisted  of  a  granular  albuminous  exudation,  granule 
cells,  dilatation  of  capillaries,  with  softening  of  their  walls,  and 
pigmentation  of  the  ganglion  cells,  especially  in  the  nuclei  of 
origin  of  the  hypoglossus  and  vagus.  Analogous  changes  were 
found  in  various  parts  of  the  cerebrum,  cerebellum,  and  basal 


EPILEPSY.  935 

ganglia.  The  cortex  of  the  brain  is  affected,  either  directly  or 
indirectly  in  the  large  majority  of  cases  of  epilepsy.  The 
primary  morbid  change  may  then  be  found  in  the  skull,  dura 
mater,  pituitary  body,  the  cortex  itself,  or  even  the  white  sub- 
stance beneath  it ;  but  it  is  probable  that  implication  of  the 
cortex  by  the  lesion  is  the  essential  condition  in  all  of  them. 
In  epileptiform  seizures,  from  coarse  disease  of  the  brain,  the 
lesion  is  always  situated  in  or  near  the  cortex  of  the  brain. 

Experimental  Researches. — The  connection  subsisting  between  general 
convulsions  and  ansemia  of  the  brain  has  ah-eady  been  considered.  Kuss- 
maul  and  Tenner  found  that  when  the  brain  in  animals  is  rapidly  deprived 
of  arterial  blood,  either  by  bleeding  or  ligature  of  the  four  great  arteries 
going  to  the  head,  general  convulsions  and  loss  of  consciousness  were 
invariably  produced.  They  also  endeavoured  to  produce  an  epileptic 
attack  by  faradisation  of  the  sympathetic,  but  only  succeeded  in  one  case 
after  both  vertebrals  and  one  carotid  were  ligatured.  The  experiments  of 
Brown-Sequard  on  guinea-pigs,  with  the  view  of  determining  the  nature 
of  epilepsy,  are  very  important.  He  found  that  injury  to  various  parts 
of  the  nervous  system  developed  in  these  animals  an  epileptic  condition. 
Section  of  some  of  the  larger  nerve  trimks,  such  as  the  sciatic,  internal 
popliteal,  and  posterior  roots  of  the  nerves  of  the  leg,  partial  or  complete 
section  of  the  spinal  cord,  and  wounding  of  the  medulla,  crura  cerebri,  or 
corpora  quadrigemina  are  the  lesions  most  surely  followed  by  epilepsy. 
After  the  wounds  heal  a  state  of  increased  excitability  persists ;  spasmodic 
twitches  appear  first  in  certain  groups  of  muscles,  and  after  a  time  the 
animals  are  seized  with  complete  epileptic  attacks.  He  also  found  that 
irritation  of  the  skin  over  a  certain  limited  area  in  the  antero-lateral  region 
of  the  neck — generally  the  area  of  distribution  of  the  trigeminus  and 
occipitalis — determines  an  epileptic  attack,  and  that  a  considerable  pro- 
portion of  the  subsequent  progeny  of  those  animals  are  epileptics. 

At  the  meeting  of  the  British  Association  at  Liverpool,  where  I  was 
present,  Dr.  Brown-S^quard  exhibited  a  descendant  of  a  guinea-pig  that  had 
become  epileptic  from  section  of  the  sciatic  nerve,  and  on  gently  ruffling 
the  hair  at  the  back  of  one  ear  an  epileptic  attack  was  induced.  The  por- 
tion of  skin,  irritation  of  which  causes  the  epileptic  attack,  Brown-Sdquard 
has  called  the  epileptogenous  zone,  and  it  is  important  to  notice  that  it  is 
slight  and  superficial  irritation  of  it  which  provokes  the  attack  ;  severe 
irritation,  like  pinching,  may  even  arrest  a  commencing  attack,  and  if  the 
skin  is  burned  or  cut  it  loses  its  epileptogenous  character.  The  skin  of  the 
area  is,  indeed,  to  a  certain  degree  anaesthetic,  and  in  the  animals  which  after 
a  long  time  recover,  as  some  of  them  do,  the  anaesthesia  of  the  epilepto- 
genous zone  gradually  diminishes,  and  disappears  along  with  the  epileptic 
tendency. 

Another  noteworthy  circumstance  with  respect  to  the  epileptogenous* 


936  EPILEPSY. 

zone  is  that  it  is  always  found  on  the  same  side  as  the  injury  of  the  nerve 
or  spinal  cord,  but  on  the  opposite  side  to  the  injury  when  the  crus  cerebri 
has  been  wounded. 

Westphal  found  that  a  light  tap  on  the  head  of  a  guinea-pig  is  followed 
by  an  attack  of  general  convulsions.  The  animal  soon  recovers  and  may 
appear  well  for  some  weeks,  but  after  a  time  an  epileptogenous  zone  is 
developed,  irritation  of  which  provokes  epileptic  attacks,  and  the  attacks 
also  occur  spontaneously. 

Hitzig  has  induced  artificial  epilepsy  by  injury  to  the  cortical  centre  of 
the  anterior  extremity  ;  and,  according  to  Terrier,  an  epileptic  attack  may 
be  induced  by  passing  an  induction  current  of  moderate  strength  through 
the  cortex  of  one  of  the  hemispheres.  In  the  case  of  a  woman  whose  brain 
was  more  or  less  exposed,  in  consequence  of  cancerous  ulceration  of  the 
skull.  Dr.  Bartholow  applied  an  induction  current  directly  to  the  brain  in 
the  region  of  the  postero-parietal  lobe — a  proceeding  which  was  followed  by 
convulsions  of  the  opposite  extremities. 

Various  experiments  have  been  undertaken  with  the  view  of  determining 
the  starting  point  of  the  general  convulsions  in  epilepsy.  The  most  suc- 
cessful of  this  kind  are  those  of  Nothnagel,  who  proved  that  general  con- 
vulsions may  be  induced  by  irritation  of  a  circumscribed  spot  on  the  floor 
of  the  fourth  ventricle,  a  spot  which  he  calls  the  "  convulsion  centre." 

§  959.  Morbid  Physiology. — In  idiopathic  epilepsy  no  con- 
stant anatomical  lesion  has  been  discovered,  and  it  may 
therefore  be  inferred  that  the  lesion  is  a  molecular  one.  The 
question  we  have  now  to  determine  is  whether  the  lesion  is  a 
diffused  one,  affecting  the  whole  nervous  system,  or  a  local  one, 
affecting  only  a  definite  region.  In  anaemia,  for  instance,  there 
is  an  excess  of  irritability  of  the  whole  nervous  system,  rendering 
the  patients  subject  to  mental  irritability,  and  less  able  to  with- 
stand any  external  causes  of  irritation.  In  such  cases  there  is 
excess  of  the  irritability  of  the  nervous  system  generally,  but 
something  more  than  this  is  necessary  to  constitute  epilepsy.  It  is 
not  sufficient  that  there  should  be  a  diffused  excess  of  irritability; 
the  nature  of  the  epileptic  paroxysm  and  its  periodic  recurrence 
point  to  the  existence  of  a  rupture  of  the  natural  balance 
between  the  degree  of  irritability  of  different  parts  of  the 
nervous  system,  or,  in  other  words,  to  a  state  in  which  some 
part  or  parts  of  the  nervous  system  develop  increased  irritability, 
while  the  remaining  portions  retain  the  normal  amount.  It  now 
becomes  necessary  to  determine  more  minutely  the  part  of  the 
nervous  system  where  the  molecular  lesion  is  situated.  Different 
regions  of  the  nervous  system  may  be  affected  in  different  cases. 


EPILEPSY.  937 

In  some  cases  there  is  an  epileptogenous  zone,  in  others  it  is 
absent;  and  in  some  again  the  sciatic  nerve  has  been  injured, 
and  probably  remains  in  a  permanently  irritable  condition. 
Injury  to  the  spinal  cord,  the  tissues  of  which  may  be  presumed 
to  remain  in  an  abnormal  state  of  irritability,  may  also  be  a 
source  of  epilepsy.  But  the  more  or  less  uniform  character  of 
the  epileptic  paroxysm  shows  that,  no  matter  what  other 
regions  may  be  affected,  a  molecular  disturbance  must,  take 
place  in  some  one  definite  region  of  the  nervous  system  in 
every  attack.  Is  it  possible  to  localise  this  region  ?  The  most 
important  problems  in  the  pathology  of  epilepsy  cluster  around 
the  answer  to  this  question. 

The  epileptic  paroxysm  consists  of  loss  of  consciousness  and 
convulsions,  and  our  problem  now  is  to  determine  what  are  the 
localities  disturbance  of  which  will  produce  these  functional 
disturbances.  Nothnagel  has  shown  that  there  is  a  certain 
limited  spot  in  the  floor  of  the  fourth  ventricle  by  irritation 
of  which  it  is  possible  to  throw  the  whole  of  the  voluntary 
muscles  into  tonic  and  clonic  spasms,  and  he  has  consequently 
named  it  the  "  convulsion  centre."  He  believes  that  irritation 
of  this  centre  is  a  necessary  concomitant  of  every  epileptic 
paroxysm.  But  although  irritation  of  this  centre  might 
account  for  the  convulsions  it  would  not  account  for  the  loss 
of  consciousness.  But  the  vaso-motor  centre  which  is  situated 
between  the  upper  part  of  the  medulla  oblongata  and  the  pons, 
close  to  the  convulsion  centre,  is  also  supposed  to  be  implicated 
in  the  molecular  disturbance  during  the  paroxysm.  Irritation 
of  the  vaso-motor  centre  causes  contraction  of  all  the  arteries  of 
the  body,  including  the  arteries  of  the  brain,  and  it  is  to  the 
anaemia  caused  by  the  contraction  of  the  vessels  of  the  brain 
that  the  loss  of  consciousness  is,  according  to  this  theory,  to  be 
attributed.  Combined  excitation  of  the  vaso-motor  and  con- 
vulsion centres  is  then,  according  to  Nothnagel's  theory,  the 
necessary  pathological  condition  of  the  epileptic  paroxysm ; 
excitation  of  the  former  centre  induces  contraction  of  the  vessels 
of  the  brain  and  the  consequent  anaemia  causes  loss  of  con- 
sciousness ;  while  excitation  of  the  latter  centre  induces  the 
muscular  contractions.  The  muscles  of  the  face  and  neck  are 
first  attacked  by  convulsions,  and  by  their   contractions  the 


938  EPILEPSY. 

large  veins  of  the  neck  are  pressed  upon  and  the  return  of 
blood  from  the  brain  is  thus  prevented,  so  that  the  ancemia  of 
the  first  moments  is  succeeded  by  an  intense  venous  hyper - 
aemia  which  augments  the  irritability  of  the  convulsion  centre 
and  prolongs  the  convulsion  and  coma.  Kussmaul  and  Tenner 
have  shown  that  when  the  brain  is  rapidly  deprived  of  arterial 
blood,  either  by  bleeding,  ligature,  or  compression  of  the  four 
great,  arteries  going  to  the  head,  coma  and  general  epileptic 
twitchings  are  invariably  produced.  It  must  be  remembered, 
however,  that  they  did  not  succeed  in  a  single  instance  in 
producing  loss  of  consciousness  merely  by  faradisation  of  the 
cervical  sympathetics.  And  if  the  local  contraction  of  the  main 
arteries  of  the  brain  caused  by  faradisation  of  the  cervical 
sympathetics  will  not  cause  loss  of  consciousness  or  convulsions, 
it  is  not  probable  that  the  contraction  of  the  arteries  of  the 
body  generally  caused  by  excitation  of  the  vaso-motor  centre 
will  cause  these  states,  inasmuch  as  the  general  arterial  tension 
will  be  raised  and  the  more  powerful  contractions  of  the  heart 
which  will  ensue  will  maintain  the  cerebral  circulation.  This 
hypothesis  also  overlooks  the  fact  that  loss  of  consciousness  is 
the  predominant  feature  of  epilepsy,  and  not  the  convulsions. 
Some  cases  of  true  epilepsy  are  characterised  by  slight  tem- 
porary loss  of  consciousness  without  any  appreciable  motor 
disturbance,  a  state  which  differs  widely  from  syncope  caused 
by  anaemia  of  the  brain,  and  is  unlikely  to  be  caused  by  vaso- 
motor action. 

Dr.  Todd  was  the  first  to  attribute  epilepsy  to  an  explosion 
of  nerve  force ;  but  this  theory  has  assumed  definite  shape  in 
the  hands  of  Dr.  Hugh  lings- Jackson,  who  suggested  that  con- 
vulsions of  all  kinds  associated  with  loss  of  consciousness  were 
caused  by  discharging  lesions  of  the  cortex  of  the  brain.  This 
hypothesis  has  received  a  considerable  amount  of  experimental 
verification.  Hitzig  was  able  to  determine  epileptic  paroxysms 
by  various  injuries  to  the  cortex  of  the  brain,  and  Ferrier 
obtained  a  similar  result  by  passing  a  faradic  current  of 
moderate  intensity  through  the  cortex,  the  electrodes  being 
widely  separated,  so  that  a  large  portion  of  the  cortex,  was 
included  in  the  circuit. 

A  survey  of  the  anatomical  changes  found  in  epilepsy  has 


EPILEPSY.  939 

already  shown  us  that,  of  all  the  manifold  lesions  observed, 
disease  of  the  cortex  of  the  brain  predominates.  Other  facts 
tend  to  the  same  conclusion,  such  as  that  where  epilepsy  is 
associated  with  imbeciUty,  structural  changes  are  often  found  on 
the  surface  of  the  brain,  and  that  general  paralysis  of  the  insane, 
a  disease  in  which  structural  changes  are  generally  found  in  the 
cortex  of  the  preefrontal  region,  is  very  often  accompanied  by 
epilepsy. 

According  to  Todd's  theory,  as  elaborated  by  Hughlings- 
Jackson,  the  convulsions  of  epilepsy  are  due  to  a  large  discharge 
of  nervous  energy  from  the  cortex  of  the  brain  along  the  cen- 
trifugal nerve  paths,  and  the  loss  of  consciousness  is  caused  by 
the  temporary  exhaustion  which  succeeds  to  excessive  nervous 
discharge.  The  temporary  paralysis  of  the  convulsed  limbs 
observed  after  epileptiform  seizures  is  also,  according  to  this 
theory,  due  to  temporary  exhaustion  of  nerve  force  following  the 
excessive  discharge.  But,  if  this  be  so,  it  may  be  asked,  why  are 
general  convulsions  not  followed  by  temporary  paralysis  ?  The 
reply  is  that  they  are  so  followed.  After  an  epileptic  attack 
there  is  complete  muscular  relaxation,  but  as  the  patient  is  at 
the  same  time  unconscious  the  degree  of  paralysis  present  can- 
not be  estimated.  Even  after  consciousness  is  regained,  general 
muscular  feebleness  often  remains  for  a  time,  which,  although 
not  called  paralysis,  is  really  paralytic  in  nature  (Hughlings- 
Jackson).  The  unseemly  and  apparently  immoral  actions  per- 
formed, and  the  atrocious  crimes  often  committed  by  patients 
after  minor  attacks  of  epilepsy,  may  be  explained  on  the  sup- 
position that  the  inhibitory  influence  of  the  highest  centres  is 
temporarily  suspended,  thus  permitting  the  centres  which  pre- 
side over  automatic  actions  and  animal  instincts  to  spring  into 
greater  activity  (Anstie).  Irritation  of  the  peripheral  nerves  or 
of  the  floor  of  the  fourth  ventricle  may  determine  the  nervous 
discharge  from  the  cortex  which  constitutes  epilepsy,  as  well  as 
direct  irritation  of  the  cortex  itself. 

Epileptiform  seizures  are  always  caused  by  a  coarse  lesion 
situated  in  or  near  the  area  of  distribution  of  the  Sylvian  artery 
to  the  cortex,  and  it  may,  therefore,  be  inferred  that  when 
attacks  of  idiopathic  epilepsy  are  ushered  in  by  a  motor  aura, 
the  molecular  disturbance  begins  in  some  part  of  the  motor 


940  EPILEPSY. 

area  of  the  cortex.  When,  on  the  other  hand,  the  aura  consists 
of  sensory  disturbances,  the  discharge  probably  begins  in  the 
area  of  the  cortex  supplied  by  the  posterior  cerebral  artery. 
When  the  aura  consists  of  emotional  states  of  fear  and  anger,  it 
is  probable  that  the  discharge  also  begins  in  the  area  of  the 
posterior  cerebral  artery,  inasmuch  as  these  emotions  are  pro- 
bably often  preceded  by  hallucinations  of  the  senses,  or  at  least 
by  some  disturbance  of  the  sensory  apparatus.  When  the  aura 
consists  of  "  dreamy "  states,  the  discharge  probably  begins 
in  the  region  of  the  cortex  supplied  by  the  anterior  cerebral 
artery,  and  the  cases  in  which  unconsciousness  supervenes 
suddenly  without  being  preceded  by  an  aura  probably  also  take 
origin  in  a  molecular  disturbance  of  this  area. 

§  960.  Diagnosis. — Epilepsy  is  often  simulated  by  impostors, 
and  sometimes  so  successfully  that  it  is  very  difficult  to  detect 
the  fraud.  The  physician  must  take  into  consideration  all 
the  circumstances  of  the  case,  but  the  symptoms  which  can 
hardly  be  simulated  are  pallor  of  the  face,  and  dilatation 
and  insensibility  to  light  of  the  pupil  at  the  beginning  of 
the  seizure.  The  slighter  attacks  of  epilepsy  are  frequently 
described  by  the  patient  as  slight  "fainting  fits,"  and  it  is 
somewhat  difficult  to  distinguish  the  two  affections.  If  the 
attacks  recur  at  regular  intervals  in  the  absence  of  any  distur- 
bance of  the  circulation  to  account  for  them,  they  must  be 
regarded  as  epilepsy.  The  diagnosis  is  rendered  clearer  if,  in 
addition,  an  epigastric  or  other  sensory  aura  be  described,  or 
if  the  attack  be  attended  by  convulsion,  twitching,  or  impaired 
consciousness. 

Hysteria  in  its  ordinary  form  may  be  readily  distinguished 
from  epilepsy  by  the  history  of  the  case  before  the  attack,  and 
by  the  absence  of  the  distortion  of  the  features,  dilatation  and 
insensibility  of  the  pupils.  Hysterical  attacks  are  unaccom- 
panied by  complete  loss  of  consciousness,  the  tongue  is  not 
bitten,  there  is  no  marked  asphyxia,  and  the  patient,  although 
exhausted,  does  not  pass  into  stupor  before  recovery.  The 
diagnosis  between  hysteria  and  hystero- epilepsy  is  readily 
made  when  the  patient  is  seen  during  an  attack.  Attacks 
of  the  latter  are  always  preceded  by  an  aura,  and  there  is  com- 


EPILEPSY.  941 

plete,  although  it  may  be  transitory,  loss  of  consciousness.  The 
diagnosis  between  epilepsy  and  eclampsia  will  be  considered 
when  the  latter  disease  is  under  consideration. 

When  organic  diseases  of  the  nervous  system  are  attended 
with  convulsions,  they  present  other  symptoms  over  and  above 
the  fits  by  means  of  which  they  may  be  distinguished  from 
epilepsy.  The  most  usual  intracranial  diseases  associated  with 
convulsions  are  tumour,  chronic  softening,  and  chronic  menin- 
gitis ;  but  in  all  these  diseases  some  characteristic  symptoms, 
such  as  optic  neuritis,  paralysis,  or  persistent  psychical  distur- 
bances, are  present,  which  render  the  diagnosis  between  them 
and  genuine  epilepsy  comparatively  easy. 

§  961.  Prognosis. — The  prognosis  in  genuine  epilepsy  is 
unfavourable  as  regards  complete  and  permanent  recovery, 
especially  if  the  disease  has  been  established  for  some  time.  It 
ought,  however,  to  be  remembered  that  a  few  cases  are  com- 
pletely curable,  and  that,  even  when  the  disease  has  been  of 
long  standing,  a  considerable  improvement  may  take  place.  In 
a  considerable  number  of  cases,  probably  the  majority,  no  treat- 
ment has  hitherto  produced  any  beneficial  effect. 

The  following  circumstances  influence  the  prognosis.  Here- 
ditary taint  gives  an  unfavourable  indication;  but  an  early 
commencement  of  the  disease  is  favourable.  Herpin  thinks 
that  when  epilepsy  begins  after  the  fiftieth  year  the  prospects 
are  still  better.  The  longer  the  disease  has  lasted,  the  greater 
the  improbability  of  recovery.  Reynolds  thinks  that  those  cases 
in  which  the  intervals  between  the  attacks  are  much  prolonged 
are  less  amenable  to  treatment  than  are  those  which  exhibit  a 
more  rapid  recurrence,  while  Herpin  thinks  that  the  prognosis 
becomes  more  unfavourable  in  proportion  to  the  number  of 
seizures  suffered  in  a  given  time.  When  the  epileptic  attacks 
are  caused  by  peripheral  irritation  the  prognosis  is  favourable, 
unless  the  disease  has  already  been  long  established,  while  of 
course  on  the  other  hand  central  disease  renders  the  prognosis 
unfavourable.  Mental  failure  is  of  evil  omen,  since  it  indicates 
in  all  probability  that  a  profound  and  permanent  molecular 
change  has  taken  place  in  the  grey  matter  of  the  cortex.  The 
danger  to  life  is  remote,  since  it  is  rare  for  an  epileptic  to  die 
in  one  of  the  attacks. 


942  EPILEPSY. 

§  962.  Treatment. — The  treatment  of  epilepsy  must  be 
directed  to  the  removal  of  the  conditions  upon  which  the 
attacks  depend,  and  to  the  mitigation  or  avoidance  of  the 
seizures  themselves. 

When  the  attacks  are  maintained  by  a  peripheral  source  of 
irritation,  this  must,  of  course,  be  removed  if  possible.  Epilepsy 
has  sometimes  been  known  to  disappear  after  the  extirpation  of 
a  cicatrix,  the  removal  of  a  tumour  pressing  on  a  nerve,  or  the 
opening  of  an  abscess;  and  the  same  result  has  been  obtained 
by  the  removal  of  sources  of  irritation  in  the  alimentary  canal, 
such  as  worms.  When  an  aura  constantly  recurred  in  the 
course  of  the  same  nerve,  it  was  formerly  the  practice  to 
perform  neurotomy,  or  to  amputate  a  finger  or  even  the  arm. 
No  good  results  attended  this  practice,  and  it  is  now  abandoned. 
The  practice  of  trephining  was  also  extensively  employed  in 
former  times  in  every  case  which  resisted  medical  treatment,  and 
this  treatment  may  possibly  be  successfully  used  in  a  limited 
number  of  cases  of  epilepsy  from  organic  disease.  It  is  scarcely 
necessary  to  add  that  in  epilepsy,  as  in  all  other  chronic  diseases, 
the  general  health  must  be  carefully  attended  to  and  the  diet 
regulated.  Alcohol,  tea,  and  coffee  should  be  sparingly  used  as 
articles  of  diet. 

Excessive  mental  effort,  emotional  excitement,  and  worry 
must  be  avoided ;  but  a  moderate  degree  of  intellectual  work 
may  be  useful,  and  a  certain  amount  of  bodily  exercise,  short 
of  fatigue,  should  be  enjoined. 

Some  epileptics  have  been  much  improved  by  the  treatment 
adopted  in  hydropathic  establishments.  The  application  of  ice 
bags  along  the  spine  was  strongly  recommended  by  Chapman ; 
but  Reynolds,  who  has  given  the  treatment  a  fair  trial,  says 
that  he  has  found  the  results  absolutely  negative.  Electricity 
in  its  various  forms  has  been  employed  in  the  treatment  of 
epilepsy,  but  with  little  success. 

Counter-irritation  was  at  one  time  extensively  used,  but  the 
prevailing  opinion  at  present  is  that  the  practice  is  useless. 
If  the  presence  of  an  epileptogenous  zone  be  ascertained,  a 
blister  over  the  sensitive  area  may  be  attended  with  benefit. 

Bromide  of  potassium  has  been  found  more  generally  useful 
in  the  treatment  of  epilepsy  than  any  other  drug ;  to  do  good 


\ 


EPILEPSY.  943 

it  must  be  given  in  doses  ranging  from  ten  to  forty  grains 
three  times  daily.  The  results  of  this  treatment  are  that  a  few- 
cases  have  been  completely  cured ;  in  other  cases  the  attacks 
have  been  arrested  for  varying  periods  of  months  or  years,  but 
have  recurred  on  the  drug  being  omitted,  and  ceased  again  on 
its  being  readministered.  In  still  other  cases  the  attacks  have 
been  diminished  in  severity,  although  not  removed ;  while  m  a 
few  cases  the  drug  does  not  appear  to  exert  any  influence  on 
the  disease.  When  large  doses  of  bromide  of  potassium  are 
administered  for  some  time,  it  is  apt  to  produce  an  eruption  of 
acne,  which  soon  subsides  on  the  drug  being  discontinued ;.  or 
the  eruption  may,  according  to  Dr.  Wilks,  be  prevented  by 
combining  arsenic  with  the  bromide.  Chloral  is  sometimes  a 
useful  adjunct  to  the  bromide  of  potassium.  Next  to  the 
bromide  of  potassium  the  salts  of  zinc,  especially  the  oxide, 
have  proved  the  most  generally  useful  in  the  treatment  of  the 
disease.  This  remedy  appears  to  be  more  efficient  with  patients 
under  twenty  years  of  age  than  in  those  of  maturer  age.  The 
oxide  may  be  given  in  doses  ranging  from  two  to  five  grains 
three  times  daily.  The  sulphate  has  also  been  employed  in 
large  doses  with  frequent  success.  The  sulphate  may  be  given 
at  first  in  doses  of  three  grains,  and  progressively  increased  to 
scruple  doses  three  times  a  day.  The  bromide  of  zinc  has  been 
administered  in  gradually  increasing  doses  up  to  a  scruple  three 
times  a  day. 

The  oxide  of  zinc  may  be  combined  with  the  extract  of  bella- 
donna or  hyoscyamus,  or  with  the  powdered  root  of  valerian. 

The  ammonio- sulphate  of  copper  was  at  one  time  much  used 
in  the  treatment  of  epilepsy,  but  has  lately  fallen  into  disuse. 

The  nitrate  of  silver  was  at  one  time  much  relied  upon  in  the 
treatment  of  epilepsy,  but  confidence  in  its  curative  power  is 
much  shaken  in  the  present  day.  The  records  of  the  older 
authors,  however,  amply  prove  that  beneficial  results  followed 
its  employment,  and  it  may  be  worth  while  to  give  it  a  trial 
when  other  methods  of  treatment  have  failed. 

Belladonna  has  been  long  used  as  a  remedy  for  epilepsy,  and 
recently  its  alkaloid,  atropine,  has  been  substituted  for  it.  The 
judgment  formed  by  Reynolds  is  now  pretty  generally  endorsed 
by  authors,  namely,  that  by  means  of  belladonna  an  amelioration 


944  EPILEPSY. 

is  often  obtained  for  various  troublesome  concomitant  symptoms, 
such  as  disturbed  sleep,  trembling,  and  nervous  uneasiness. 

Digitalis,  either  alone  or  in  combination  with  bromide  of 
potassium,  is  useful  in  some  cases,  especially  if  there  be  signs  of 
cardiac  failure. 

Indian  hemp  has  been  found  useful  as  an  accessory  in  the 
treatment  of  epilepsy,  and  by  its  means  headache  and  restless- 
ness have  been  relieved,  but  it  does  not  appear  even  to  have 
appreciably  mitigated  the  disease. 

If  there  be  a  suspicion  of  syphilis  being  the  cause  of 
epilepsy,  iodide  of  potassium  should  of  course  be  given. 

The  treatment  of  the  attack  should  be  directed  to  its  preven- 
tion, and  this  is  only  possible  when  it  is  preceded  by  a  distinct 
warning.  When  an  "  aura "  is  present,  the  attack  may  some- 
times be  arrested  by  cauterising  or  blistering  the  surface  from 
which  the  aura  commences,  or  by  applying  pressure,  as  by  a 
tight  ligature,  between  the  starting  point  of  the  aura  and  the 
trunk.  Some  patients  are  able  to  arrest  the  paroxysm  by  a 
strong  mental  effort  to  perform  a  definite  action. 

When  the  aura  consists  of  contraction  of  a  definite  group  of 
muscles,  the  attack  may  be  arrested  by  forcible  extension  of 
them.  There  are  some  grounds  for  believing  that  the  paroxysm 
may  be  sometimes  arrested  by  a  sudden  impression  on  the 
surface  of  the  body.  Inhalation  of  chloroform  or  of  ammonia, 
or  a  draught  of  some  diffusible  stimulant  administered  at  the 
moment  of  onset,  may  arrest  an  attack. 

Dr.  Crichton  Browne  was  able  to  ward  off  several  attacks  by 
causing  the  patients  to  inhale  nitrite  of  amyl  when  a  fit 
threatened.  The  well-known  action  of  this  agent,  in  paralysing 
the  vaso-motor  nerves,  supplies  the  rationale  of  the  treatment. 

When  the  attack  is  once  established,  it  passes  through  its 
regular  phases  without  being  influenced  by  treatment.  Measures 
must  be  adopted  for  preventing  the  patient  injuring  himself. 
All  tight  bands  about  the  throat  must  be  loosened,  and  a  piece 
of  indiarubber  or  wood  should  be  passed  between  the  teeth,  to 
prevent  the  tongue  being  bitten. 

When  the  paroxysm  is  over,  the  patient  ought  to  be  placed 
with  the  head  and  shoulders  raised,  and  allowed  to  sleep  without 
interference. 


ECLAMPSIA.  945 

If  the  paroxysm  be  long  continued,  so  that  there  is  danger 
of  death  supervening  from  congestion  of  the  lungs,  blood-letting 
may  relieve  the  circulation  so  much  as  to  arrest  the  attack. 
When  the  fits  are  violent,  a  careful  trial  may  be  made  of  the 
inhalation  of  chloroform,  which  is  so  useful  in  the  treatment  of 
eclampsia. 

(II.)    ECLAMPSIA. 

§  963.  Definition. — Eclampsia  is  an  acute  affection  arising 
without  structural  lesion  of  the  nervous  system,  and  charac- 
terised by  partial  or  general  convulsions,  accompanied  by  a 
more  or  less  complete  loss  of  consciousness. 

§  964.  Etiology. — Age  is  a  most  important  predisposing  cause 
of  eclampsia.  Convulsions  are  frequent  during  the  first  two 
years  of  life,  but  become  rare  after  the  fifth  and  exceptional 
after  the  seventh  year  of  life. 

The  influence  of  hereditary  predisposition  in  the  production 
of  convulsions  is  shown  by  the  fact  that  successive  infants  of 
one  family  are  liable  to  be  attacked  with  convulsions  in  the 
absence  of  any  definite  cause.  Bouchut  mentions  an  instance 
of  a  family  of  ten  persons,  all  of  whom  had  convulsions  in 
infancy.  One  of  these  married  and  had  ten  children,  and  nine 
of  them  suffered  from  convulsions.  The  children  of  parents 
who  manifest  evidences  of  a  neuropathic  constitution,  as  hys- 
teria, neuralgia,  or  epilepsy,  are  more  liable  to  be  attacked  by 
convulsions  than  the  children  of  the  healthy. 

All  debilitating  causes,  as  insufficient  food,  profuse  diarrhoea, 
copious  hsemorrhages,  malarial  cachexia,  and  various  diseases, 
greatly  increase  the  tendency  to  convulsions.  Amongst  the 
debilitating  diseases  which  predispose  to  convulsions  rickets 
holds  a  prominent  place.  Out  of  65  infants  attacked  with 
convulsions,  Dr.  Gee  found  that  no  less  than  56  of  the  number 
were  rachitic.  Convulsions  occur  more  frequently  in  children 
during  hot  than  cold  weather,  and  some  authors  assert  that 
they  are  more  frequent  in  female  than  in  male  infants,  but  the 
influence  of  sex  is  not  well  ascertained. 

Eclampsia  has  been  divided  into  several  varieties  according 
to  the  exciting  cause  of  the  convulsions.  These  are  :  (1),  Idio- 
III 


946  ECLAMPSIA. 

pathic  convulsions ;  (2),  Reflex  convulsions ;  (3),  Convulsions 
of  fever ;  (4),  Convulsions  of  asphyxia ;  (5),  Ursemic  convulsions ; 
(6),  Puerperal  convulsions  ;  (7),  Toxic  convulsions. 

(1)  In  idiopathic  convulsions  the  exciting  is  quite  subordi- 
nate to  the  predisposing  cause.  Some  children  are  so  pre- 
disposed to  convulsions  that  the  slightest  exciting  cause,  such 
as  fear,  anger,  or  a  slight  colic,  may  induce  a  convulsion,  while 
at  other  times  an  attack  supervenes  in  the  entire  absence  of 
any  appreciable  cause, 

(2)  Refiex  convulsions  are  occasioned  by  irritation  of  the 
extremities  of  the  peripheral  nerves.  The  nature  and  situation 
of  the  external  irritation  varies  indefinitely.  Amongst  the  most 
usual  causes  of  irritation  pricking  by  pins,  wounds  and  burns 
of  the  surface  of  the  body,  retention  of  urine,  the  presence  of  a 
calculus  in  the  kidney,  foreign  bodies  in  the  external  auditory 
meatus,  and  irritation  of  the  digestive  canal  from  the  presence 
of  worms  or  undigested  food  aod  of  tbe  gums  during  painful 
dentition  may  be  mentioned. 

(3)  Febrile  convulsions  manifest  themselves  at  the  outset  of 
acute  diseases,  more  particularly  in  lobar  pneumonia,  the  erup- 
tive fevers,  and  intermittent  fever. 

This  form  of  convulsion  appears  to  correspond  to  the  rigor 
which  ushers  in  most  acute  febrile  diseases  in  the  adult ;  and 
if  not  caused,  it  is  at  least  accompanied  by  rapid  elevation  of 
temperature.  It  must  not  be  confounded  with  the  convulsions 
which  supervene  in  the  course  of  febrile  diseases,  since  the 
latter  are  usually  symptomatic  of  cerebral  hypersemia,  or  of 
some  form  of  meningitis. 

(4)  Convulsions  due  to  asphyxia  occur  in  the  course  of 
diseases  of  the  respiratory  organs ;  they  are  frequently  observed 
during  severe  attacks  of  whooping  cough,  and  may  appear  as 
terminal  phenomena  in  most  of  the  diseases  of  infancy. 

(5)  Urcemic  convulsions  in  children  generally  result  from 
scarlatinal  nephritis,  but  they  have  been  occasionally  observed 
immediately  after  birth.  These  convulsions  are  also  observed 
in  other  forms  of  both  acute  and  chronic  nephritis. 

(6)  Puerperal  eclampsia  is,  as  a  rule,  merely  a  form  of 
uraemic  convulsions,  although  some  cases  are  probably  caused 
by  reflex  irritation  through  the  uterine  nerves  or  the  sacral 
plexus. 


ECLAMPSIA.  947 

(7)  Toxic  convulsions  might  be  held  to  include  uraemic 
convulsions,  inasmuch  as  the  latter,  according  to  some  patho- 
logists, result  from  the  accumulation  of  urea  in  the  blood,  and 
its  conversion  into  carbonate  of  ammonia.  This  hypothesis  is, 
however,  doubtful,  and  it  is  therefore  better  to  place  uraemic 
convulsions  in  a  separate  category. 

Certain  metallic  and  organic  poisons  and  irrespirable  gases 
give  rise  to  attacks  of  convulsions.  Amongst  these  agents  the 
most  usual  are  prussic  acid,  nicotine,  picrotoxine,  oenanthe  cro- 
cata,  carbonic  oxide,  and  carburetted  hydrogen, 

§  965.  Symptoms. — An  attack  of  eclampsia  cannot  be  dis- 
tinguished from  a  true  epileptic  seizure,  and  it  is  therefore 
unnecessary  to  give  a  minute  description  of  it.  Infantile  con- 
vulsions have  been  divided  into  internal  and  external,  the 
muscles  of  the  glottis  and  the  respiratory  muscles  being  chiefly 
affected  by  spasm  in  the  former  and  the  muscles  of  external 
relation  in  the  latter. 

The  symptoms  caused  by  spasm  of  the  glottis  have  already 
been  described  (§  279),  and  we  shall  consequently  limit  our 
further  remarks  to  the  external  convulsions  of  children.  An 
attack  of  eclampsia  may  occur  either  with  or  without  pre- 
monitory symptoms;  the  invasion  without  prodromata  being, 
according  to  Rilliet  and  Barthez,  the  more  common. 

The  premonitory  symptoms,  when  present,  usually  consist  of 
sleeplessness,  and  restlessness  or  drowsiness  for  a  day  or  two 
before  the  attack;  while  immediately  before  it  the  pulse  is 
often  hard  and  wiry,  the  countenance  assumes  a  frightened 
expression,  or  the  child  starts  up  frightened  from  a  fitful  and 
uneasy  sleep.  The  convulsion  usually  begins  by  conjugate 
deviation  of  the  eyes,  and  slight  jerking  contractions  of  the 
muscles  of  the  angles  of  the  mouth.  The  natural  look  of  the 
infant  is  now  exchanged  for  a  fixed  stare,  followed  soon  after- 
wards by  an  upward  rotation  of  the  eyeballs,  the  latter  being  in 
its  turn  followed  by  a  fixed  stare  and  that  again  by  an  upward 
rotation  of  the  globes.  The  eyeballs  are  often  rotated  to  the 
right  or  left  as  well  as  upwards,  and  the  two  are  generally 
moved  unequally,  so  that  a  considerable  degree  of  strabismus 
may  occur.     The  pupils  are  sometimes  dilated,  sometimes  con- 


948  ECLAMPSIA. 

tractedj  and  when  they  are  completely  concealed  by  the  superior 
lids,  the  whites  of  the  eyes  being  alone  visible,  the  countenance 
assumes  a  frightful  and  characteristic  aspect. 

Clonic  spasms  of  the  facial  muscles  produce  a  series  of 
grimaces  and  contortions,  in  which  the  labial  commissures  are 
drawn  outwards,  and  at  each  successive  jerk  a  peculiar  sucking 
noise  is  made  by  the  passage  of  air  through  the  mouth,  the 
lips  being  covered  by  a  frothy,  and  often  slightly  sanguinolent 
mucus.  The  superior  lip  is  sometimes  drawn  upwards,  so  as  to 
expose  the  teeth,  and  the  countenance  then  assumes  an  almost 
savage  expression.  The  inferior  jaw  is  sometimes  agitated  by 
clonic  spasms,  while  at  other  times  there  is  trismus,  interrupted 
from  time  to  time  by  grinding  of  the  teeth.  The  head  is  usually 
strongly  retracted,  and  sometimes  rotated  to  one  side.  The 
thumb  is  flexed  into  the  palm,  and  the  fingers  are  flexed  over  the 
thumb;  the  forearm  is  bent  upon  the  arm  and  is  constantly 
agitated  by  slight  movements  of  semiflexion  and  semiextension  ; 
the  hand  is  alternately  pronated  and  supinated ;  and  the  seg- 
ments of  the  superior  extremities  are  contorted  into  every 
imaginable  shape.  The  inferior  extremities  are  affected  in  a 
similar  manner,  although  to  a  less  degree  than  the  superior 
The  muscles  of  the  trunk  occasionally  participate  in  the  clonic 
convulsions,  but  as  a  rule  the  trunk  is  maintained  rigid  by  tonic 
contraction  of  its  muscles.  The  contraction  of  the  muscles  of 
one-half  the  body  may  predominate  over  those  of  the  opposite 
side,  and  then  the  child  is  arched  laterally  in  such  a  way  that 
he  may  be  projected  out  of  bed  by  the  convulsion.  The 
spasmodic  contraction  of  the  diaphragm  and  of  the  muscles 
of  the  larynx  produce  a  peculiar  and  characteristic  noise  when 
air  is  drawn  into  the  chest  during  inspiration.  Involuntary 
evacuations  may  occasionally  take  place  during  convulsions. 
Deglutition  is  rarely  impossible,  although  attempts  to  get  the 
infant  to  swallow  during  the  convulsion  are  attended  with 
danger. 

There  is  complete  loss  of  consciousness  during  the  attack,  but 
reflex  excitability  is  partially  retained.  When  the  convulsion 
is  prolonged  the  face  becomes  of  a  violet  colour  and  bathed  in 
perspiration ;  the  head  is  hot  and  the  extremities  cold  ;  the  skin 
is  moist ;  the  pulse  is  frequent  and  difficult  to  count,  owing  to 


ECLAMPSIA.  94)9 

jerking  of  the  tendons;  and  the  respirations  are  accelerated, 
but  stertorous  only  in  aggravated  cases. 

The  ocular  muscles  and  those  of  facial  expression  are  usually 
the  first  to  be  affected  with  clonic  spasm,  and  then  the  muscles 
of  the  fingers  and  forearm.  In  the  more  severe  convulsions  the 
muscles  of  the  shoulders  are  affected,  but  the  spasms  do  not 
implicate  the  muscles  of  the  back  and  lower  extremities  except 
in.  very  aggravated  cases.  The  great  tonic  contractions  which 
form  the  first  stage  of  the  epileptic  attack  frequently  fail 
altogether  in  eclampsia. 

§  966.  Course,  Duration,  and  Terminations. — The  duration 
of  an  attack  of  eclampsia  varies  considerably  according  to 
circumstances.  The  convulsion  may  sometimes  cease  in  a  few 
minutes,  while  at  other  times  they  recur  for  hours  or  days, 
with  only  short  intervals  of  calm. 

The  terminal  convulsions  of  asphyxia  are  generally  partial, 
incomplete,  and  alternate  with  coma.  The  initial  convulsions 
of  fever  are  intense  and  generalised,  but  are  usually  limited  to 
a  single  attack.  Uroemic  convulsions  are  characterised  by  their 
violence,  the  frequent  repetition  of  the  paroxysm,  and  the  pro- 
found coma  which  alternates  with  or  succeeds  the  latter.  After 
violent  and  prolonged  convulsions  ecchymoses  of  the  skin, 
especially  over  the  face  and  eyelids,  and  acute  pains  of  the 
affected  limbs,  are  frequently  observed.  Fractures  of  long 
bones,  dislocations,  and  ruptures  of  tendons  have  been  rarely 
recorded. 

An  attack  of  convulsions  is  frequently  followed  by  complete 
and  rapid  re-establishment  of  health,  but  in  other  cases  recovery 
takes  place  slowly.  When  the  convulsion  is  due  to  a  meningeal 
haemorrhage  or  some  other  organic  lesion  of  the  brain,  it 
generally  assumes  a  unilateral  character,  and  is  followed  by 
paralysis  with  contractures,  choreiform  movements,  aphasia,  or 
idiocy.  Essential  convulsions  sometimes  end  in  death,  which 
may  result  after  a  single  violent  seizure,  or  after  a  series  of 
them  occurring  in  rapid  succession.  Death  is  usually  produced 
by  asphyxia,  either  occurring  suddenly  from  spasm  of  the  glottis, 
or  more  slowly  from  coma. 


950  ECLAMPSIA. 

967.  Diagnosis. — In  any  particular  case  of  eclampsia  it  is 
difficult  to  decide  whether  or  not  the  case  is  one  of  essential 
convulsions,  epilepsy,  or  convulsion  symptomatic  of  organic 
lesion  of  the  brain.  The  chief  points  which  ought  to  be 
attended  to  in  order  to  arrive  at  a  probable  diagnosis  are  the 
age  of  the  patient,  the  state  of  the  temperature  and  urine,  the 
character  of  the  convulsions,  and  the  previous  health  during 
the  intervals  between  the  attacks. 

Eclampsia  is  most  frequently  observed  during  the  first  years 
of  life,  and  is  rare  beyond  that  age,  except  as  the  result  of 
definite  causes;  such  as  albuminuria,  and  the  invasion  of  an 
eruptive  fever  or  other  acute  disease.  When  the  attacks  are 
repeated  beyond  two  years  of  age,  at  irregular  intervals  of 
months  or  years,  epilepsy  may  be  inferred,  unless  symptoms 
pointing  to  a  focal  lesion  of  the  brain  are  present.  The  state  of 
the  temperature  is  the  best  guide  in  deciding  between  essential 
convulsions  and  the  initial  convulsions  of  acute  diseases,  the 
thermometer  being  nearly  normal  in  the  former  and  rising  to 
between  103°  F.  and  104°  F.  in  the  latter.  The  urine  should 
always  be  examined  for  albumen  in  cases  of  convulsions,  in 
order  to  determine  whether  or  not  the  attack  depends  upon  the 
presence  of  Bright's  disease. 

If  the  convulsions  are  unilateral  in  character,  or  consist  of 
local  spasms  without  loss  of  consciousness,  they  are  likely  to  be 
due  to  organic  disease  of  the  brain  or  its  membranes,  Such 
cases  are  generally  followed  by  some  degree  of  paralysis  with 
subsequent  contracture.  If  the  convulsion  be  preceded  by  a 
well-marked  aura,  if  its  onset  be  marked  by  a  sudden  pallor  and 
a  piercing  cry,  and  if  the  first  stage  be  attended  by  well-marked 
tonic  contractions,  the  mouth  covered  by  froth,  and  the  tongue 
bitten,  the  attack  is  one  of  true  epilepsy.  In  epilepsy  the 
return  to  health  after  the  attack  is  rapid  and  perfect,  and  in 
the  intervals  between  the  severer  paroxysms  the  patient  may 
suffer  from  attacks  of  petit  mal. 

§  968.  Prognosis. — The  prognosis  of  eclampsia  depends  upon 
the  character  of  the  attacks,  and  the  causes  by  which  they  are 
produced. 

Frequent  repetition    of    the   convulsions,    the   presence   of 


ECLAMPSIA.  951 

stertor,  cyanosis,  or  spasm  of  the  glottis,  and  a  small  uncountable 
pulse  afford  a  grave  prognosis,  whatever  may  be  the  cause  of 
the  attack. 

Essential  convulsions  are  only  grave  as  indicating  a  neurotic 
disposition,  and,  when  the  attacks  recur  frequently,  there  is 
danger  lest  they  develop  into  confirmed  epilepsy. 

Convulsions  occurring  in  cachectic  infants  and  in  those 
exhausted  by  profuse  diarrhoea  are  almost  always  the  precursors 
of  death. 

The  initial  convulsions  of  fever  derive  all  their  significance 
from  the  disease  with  which  they  are  associated.  The  convul- 
sions which  occur  in  the  course  of  fevers  always  justify  a  grave 
prognosis. 

The  convulsions  of  asphyxia  are  almost  always  fatal. 
Urgemic  convulsions  terminate  more  frequently  in  recovery 
than  in  death.  If  the  infant  survive  the  first  24  or  86  hours 
he  may  be  regarded  as  safe. 

§  969.  Treatment. — The  most  obvious  indication  of  treatment 
is  to  remove  the  cause  of  the  attack,  and  in  reflex  convulsion  the 
removal  of  the  cause  is  often  successful.  If  the  gum  be  tightly 
stretched  over  a  tooth  it  may  be  scarified,  but  the  tooth  should 
be  near  the  surface  and  the  gums  hot  and  inflamed  before  this 
practice  is  adopted.  If  the  bowels  be  constipated,  and  especially 
if  they  be  tympanitic,  an  injection  of  warm  water  is  useful.  I 
have  often  seen  the  convulsions  cease  immediately  on  the 
bowels  being  opened  after  an  enema  of  warm  water.  If  the 
convulsions  are  the  result  of  a  smart  attack  of  diarrhoea,  and 
especially  if  the  fontanelles  are  depressed,  a  small  starch  enema, 
with  half  a  teaspoonful  of  brandy  and  from  2  to  5  minims  of 
tincture  of  opium,  may  be  administered.  If  there  be  grounds 
for  believing  that  the  convulsions  are  caused  by  the  presence  of 
worms,  an  anthelmintic,  and  if  from  the  presence  of  undigested 
food,  a  smart  purgative  should  be  administered.  Predisposing 
causes,  such  as  ansemia,  insufficient  nourishment,  and  rickets, 
must  be  removed  by  appropriate  treatment. 

During  the  convulsion  plenty  of  fresh  air  should  be  admitted 
into  the  room,  and  all  articles  of  clothing  should  be  removed 
from  the  neck  and  chest  of  the  infant.     A  warm  bath  is  often 


952  ECLAMPSIA. 

useful,  but  when  there  is  hyperpyrexia,  the  cold  bath  should  be 
used  in  preference.  Compression  of  the  carotids  and  bleeding 
have  been  recommended  as  means  of  arresting  the  attack,  but 
the  former  is  ineffectual  and  the  latter  only  rarely  applicable. 
The  inhalation  of  chloroform  is  by  far  the  best  method  of 
treating  attacks  of  eclampsia.  This  treatment  is  applicable  to 
all  cases  of  essential  and  ursemic  convulsions,  and  is  only  contra- 
indicated  in  cases  where  there  is  a  considerable  elevation  of 
temperature,  and  in  which  there  is  a  cyanotic  tint  of  counten- 
ance and  stertorous  breathing.  No  harm  results  from  keeping 
the  child  many  hours,  if  necessary,  under  the  full  influence  of 
chloroform.  When  once  the  infant  is  able  to  swallow,  bromide 
of  potassium  or  chloral  hydrate  may  be  given  either  separately 
or  combined.  A  grain  of  the  bromide  of  potassium  for  each  year 
of  age  may  be  given  every  four  hours,  and  its  efficacy  appears 
to  be  increased  by  adding  an  equal  quantity  of  chloral  to  each 
dose.  If  chloral  be  given  alone,  a  full  dose — three  grains  to  a 
child  one  year  of  age — must  be  administered. 


953 


CHAPTEK  VII, 


TOXIC,   AND   FEBRILE    AND    POST-FEBRILE    NERVOUS 
DISORDERS. 


(I.)  ALCOHOLIC   NERVOUS   DISEASES. 

The  subject  of  acute  poisoning  by  alcohol  belongs  rather  to  the 
province  of  the  toxicologist  than  to  that  of  the  neurologist? 
and  will  be  passed  over  here.  Besides  a  large  number  of 
nervous  disorders  produced  by  the  ingestion  of  alcohol  need 
not  be  discussed,  inasmuch  as  alcohol  is  only  an  indirect  cause 
of  them.  Amongst  these  may  be  mentioned  apoplectic  attacks 
caused  by  degeneration  of  the  vascular  system,  and  chronic 
dementia  caused  by  hsematoma  of  the  dura  mater. 

§  970.  Delirium  Tremens. — The  symptoms  known  under  the 
name  of  delirium  tremens  occur  in  persons  after  prolonged 
indulgence  in  alcoholic  excess,  or  as  the  result  of  a  single 
debauch.  The  characteristic  features  of  the  affection  are  pre- 
ceded by  restlessness,  tremor  more  marked  in  the  hands  and  in 
the  morning,  and  wakefulness  at  night,  while  a  severe  attack 
of  vomiting  is  frequent  in  the  morning.  The  patient  is 
irritable,  suspicious,  quarrelsome,  and  agitated,  and  the  little 
sleep  obtained  is  broken  by  disagreeable  dreams.  The  appetite 
fails  completely,  so  that  little  or  no  food  is  taken  for  several  days ; 
the  breath  has  a  characteristic  foul  odour ;  the  tongue  is  tremu- 
lous on  protrusion,  red  and  glazed,  or  more  commonly  covered 
with  a  thick,  creamy  fur;  the  skin  is  bathed  in  profuse  per- 
spiration ;  the  face  is  generally  flushed,  but  occasionally  pale ; 
the  pupils  are  usually  dilated,  and  the  conjunctivse  injected ; 


954  TOXIC,  AND  FEBRILE  AND 

the  temperature  is  slightly  elevated ;  and  the  pulse  is  usually 
large,  soft,  and  dicrotous. 

Tremors  are  always  present,  and  are  only  an  aggravation  of 
a  slighter  degree  of  the  same  which  had  existed  for  months 
previously  (Anstie),  Hallucinations  of  special  sense  now  make 
their  appearance,  those  of  sight  being  most  common.  The 
patient  sees,  especially  at  night  when  about  to  go  to  sleep, 
sparks  of  fire  and  floating  bodies;  but  soon  distinct  objects, 
especially  those  productive  of  disgust  or  terror,  are  seen  in 
broad  daylight.  The  patient  sees  himself  surrounded  by  insects, 
snakes,  rats,  and  monsters  of  variable  shape,  and  armed  men 
pursuing  him  with  threatening  gestures.  He  talks  incessantly 
in  an  incoherent  and  rambling  manner,  and  looks  suspiciously 
under  the  bed,  and  in  every  corner  of  the  room,  to  satisfy  himself 
that  none  of  the  imaginary  beings  by  which  he  fancies  himself 
surrounded  are  lodging  there.  His  actions,  indeed,  appear  to 
be  largely  determined  by  the  nature  of  his  hallucinations. 
At  times  he  will  busy  himself  in  endeavouring  to  catch  the 
insects  which  crawl  over  his  bed,  or  he  will  get  up  and  search 
everywhere  for  something  which  has  disappeared  in  a  corner 
of  the  room ;  while  at  other  times  he  will  dodge  about  in  order 
to  avert  a  threatened  blow,  or  endeavour  to  run  or  hide  in 
abject  terror  behind  an  article  of  furniture,  in  order  to  escape 
from  some  pursuing  foe.  The  prevailing  mental  character 
during  the  attack  is  one  of  terror  and  cowardice,  although  the 
patient  may  occasionally  turn  upon  his  attendant  in  the  belief 
that  the  latter  is  plotting  against  him,  or  is  about  to  inflict  upon 
him  some  bodily  injury. 

As  a  rule,  the  patient  is  very  tractable  to  his  medical  atten- 
dant, and  gives  ready  obedience  to  his  commands  during  his 
visit;  but  he  is  not  unfrequently  violent  towards  his  friends, 
and  especially  to  his  wife. 

At  the  end  of  three  or  four  days,  or  at  most  a  week  from  the 
commencement,  the  patient,  when  the  attack  is  about  to  termi- 
nate favourably,  falls  into  a  quiet  sleep  and  awakes  refreshed 
and  calm.  Some  cases,  especially  if  the  patient  have  previously 
suffered  from  repeated  attacks,  terminate  fatally  by  coma  or 
asthenia.  In  fatal  cases  the  temperature  rises  to  103°  F.  or 
104°  F. ;  the  pulse  is  extremely  rapid  and  feeble ;  the  tremors 


POST-FEBRILE  NERVOUS  DISORDERS.  955 

become  general,  and  associated  with  subsultus  tendinum ; 
epileptic  convulsions,  followed  by  coma,  may  supervene  and 
prove  fatal,  or  bed-sores  appear  and  the  patient  dies  exhausted. 
Death  is  not  unfrequently  caused  by  an  intercurrent  attack  of 
pneumonia,  or  some  other  acute  disease. 

§  971.  Alcoholic  Paraplegia. — Dr.  Wilks  has  drawn  atten- 
tion to  a  condition  of  partial  paraplegia  associated  with 
anaesthesia,  or  pains  in  the  limbs,  which  is  liable  to  occur  in 
persons,  especially  women,  who  have  indulged  in  alcoholic 
excess.  Chronic  pains  in  the  limbs  may  be  complained  of  long 
before  the  symptoms  of  paralysis  appear,  or  there  may  be  a 
certain  degree  of  motor  inco-ordination.  The  immoderate  use 
of  chloral  hydrate  may  occasion  chronic  pains  in  the  limbs 
(Anstie),  and  a  distressing  case  came  under  my  own  observation 
in  which  the  same  symptoms  were  caused  by  the  prolonged 
and  intemperate  use  of  chlorodyne.  The  pains  in  the  limbs 
disappeared  rapidly  when  the  drug  was  discontinued. 

§  972.  Treatment. — The  patient  should  be  placed  in  a  dark 
room,  and  the  utmost  quiet  enjoined.  He  should  be  constantly 
watched  by  one  or  two  trustworthy  attendants,  and  the  use  of 
mechanical  means  to  restrain  his  movements  should  if  possible 
be  avoided.  Nutriment  should  be  frequently  administered  in 
the  form  of  beef-tea,  soups,  milk,  and  eggs.  A  full  dose  of 
chloral,  either  alone  or  combined  with  bromide  of  potassium, 
may  be  given  at  once,  and  smaller  doses  repeated  at  stated 
intervals.  If  sleep  be  not  procured  on  the  second  night,  a  full 
dose  of  opium  or  morphia  may  be  administered  on  the  third  and 
subsequent  evenings  at  the  usual  bed  time.  According  to  my 
experience,  opium  acts  better  when  given  after  chloral  has  been 
used  than  at  the  outbreak  of  the  symptoms.  If  symptoms  of 
asthenia  be  present,  it  may  be  necessary  to  give  a  certain  amount 
of  the  alcoholic  stimulus  to  which  the  patient  has  been  accus- 
tomed ;   but,  as  a  rule,  alcohol  should  be  wholly  forbidden. 

(II.)    SATURNINE    NERVOUS    DISEASES. 
§  973.  It  is  impossible  to  enter  into  a  full  discussion  of  all 
the  deleterious  effects  produced  by  the  prolonged  introduction 


956  TOXIC,   AND  FEBRILE  AND 

of  small  quantities  of  lead  into  the  system ;  it  must  suffice  to 
mention  a  few  of  the  leading  nervous  affections  caused  by  this 
poison. 

Chronic  lead-poisoning  at  one  time  frequently  resulted  from 
the  use  of  drinking-water  stored  in  leaden  cisterns  or  conveyed 
through  leaden  pipes,  but  this  seldom  happens  now.  Lead- 
poisoning  is  most  frequently  met  with  amongst  painters,  and 
workmen  pursuing  various  trades  in  which  lead  is  used.  The 
poison  may  enter  the  system  by  being  swallowed  along  with 
the  saliva,  through  the  lungs  by  fine  particles  of  the  carbonate 
being  diffused  in  the  air,  or  through  the  mucous  membrane  of 
the  nose  by  the  adulteration  of  snuff  with  red  lead  (Winter). 
Some  individuals  are  much  more  susceptible  to  the  action  of 
lead  than  others ;  and,  as  was  first  suggested  by  Dr.  Garrod, 
those  who  inherit  a  predisposition  to  gout  appear  to  be  parti- 
cularly liable  to  become  poisoned  by  lead. 

§  974.  Symptoms. — One  of  the  most  valuable  indications  of 
the  presence  of  lead  in  the  system  is  afforded  by  the  formation 
of  a  blue  line  along  the  edges  of  the  gums  immediately  adjoin- 
ing the  teeth.  The  blue  line,  although  situated  in  the  sub- 
stance of  the  gums,  appears  to  be  produced  b}'^  the  formation  of 
a  sulphide,  the  latter  being  formed  by  sulphuretted  hydrogen 
emitted  from  decomposing  matters  on  the  teeth. 

Sensory  Disturbance. — Phenomena  of  sensory  irritation  may 
be  manifested  in  the  form  of  hypersesthesia  of  the  superficial 
and  neuralgia  of  the  deeper  parts.  Rosenthal  states  that 
cutaneous  hypersesthesia  often  accompanies  paroxysms  of  pain, 
and  that  it  may  alternate  with  anaesthesia.  Arthralgia,  probably 
of  a  neuralgic  character,  is  a  prominent  symptom  of  chronic 
lead -poisoning.  The  pains  in  the  joints  occur  in  paroxysms, 
and  may  appear  in  the  upper  or  lower  extremities,  or  in  the 
jaws.  Lead  colic,  probably  also  of  neuralgic  origin,  is  one  of 
the  most  frequent  and  important  symptoms.  The  pains  are 
chiefly  referred  to  the  umbilical  region ;  they  are  liable  to 
paroxysmal  exacerbations  of  great  severity,  although  a  consi- 
derable degree  of  uneasiness  or  pain  remains  during  the  inter- 
vals (§  334). 

Cutaneous  ancesthesia  is,  however,  much  more  commonly 


POST-FEBRILE  NERVOUS   DISORDERS.  957 

observed  than  hypersesthesia,  and  is,  accordiDg  to  Bean,  one  of 
the  most  characteristic  symptoms  of  chronic  lead-poisoning.  It 
is  variable  in  its  distribution,  and  may  be  complete  or  incom- 
plete. Tactile  anaesthesia  is  often  associated  with  motor  para- 
lysis, colic,  or  arthralgia.  It  is  most  frequently  situated  on  the 
skin  of  the  backs  of  the  hands  and  forearms,  the  external 
surface  of  the  calves,  and  the  abdomen  and  chest,  the  skin  over 
the  epigastrium,  however,  remaining  always  free  (Bean).  Loss 
of  feeling  sometimes  extends  to  the  veil  of  the  palate  and  uvula. 
In  other  cases  analgesia,  thermo- anaesthesia,  and  loss  of  the 
sensibility  to  tickling  may  be  present,  while  tactile  sensibility 
remains  unimpaired.  The  electric  sensibility  is  often  lost 
(Raymond).  The  anaesthesia  is  often  transitory,  and,  according 
to  B-enaut,  is  sometimes  caused  by  cutaneous  anaemia,  and  may 
be  made  to  disappear  by  rubefaciants  and  profuse  diaphoresis. 

Deafness,  according  to  Tanquerel,  frequently  follows  an  attack 
of  arthralgia,  and  diminution  of  taste  on  half  the  tongue,  and 
of  smell  in  one  nostril,  has  been  observed.  But  the  affections 
of  sight  are  more  frequent  and  important  than  those  of  the 
other  special  senses.  These  consist  of  transitory  amblyopia 
without  ophthalmoscopic  changes  ;  persistent  amblyopia  passing 
on  to  amaurosis  of  both  eyes  and  rarely  of  one  only,  attended 
by  atrophy  of  the  optic  nerve ;  amblyopia  with  double  optic 
neuritis ;  and  amblyopia  with  albuminuric  retinitis,  in  asso- 
ciation with  granular  kidneys. 

Motor  Disturbances. — Motor  are  more  commonly  observed 
than  sensory  disorders  in  lead -poisoning.  Almost  all  the 
muscles  of  the  body  may  be  affected,  although  certain  groups 
are  attacked  by  preference.  In  partial  paralysis  the  extensor 
muscles  of  the  forearm  are  more  frequently  affected  than  any 
other  group ;  and  consequently  when  the  arms  are  held  out 
horizontally,  with  the  hand  in  a  state  of  pronation,  the  hand  is 
flexed  at  the  wrist  and  cannot  be  extended,  this  condition  being 
technically  called  wrist-drop.  The  common  extensors  of  the 
fingers  are  first  attacked,  then  the  extensors  of  the  index  and 
little  fingers,  and  lastly,  in  succession,  the  extensor  secundi 
internodii  pollicis,  the  extensors  of  the  wrist,  the  extensor  primi 
internodii  pollicis,  and  the  extensor  ossis  metacarpi  pollicis.  The 
supinator  longus  is  spared  until  a  comparatively  late  period  of 


958  TOXIC,  AND  FEBRILE  AND 

the  disease,  and  is  never  affected,  according  to  Remak,  unless 
the  paralysis  extend  to  the  muscles  of  the  upper  arm.  Some- 
times the  paralysis  begins  in  the  muscles  of  the  upper  arm,  and 
then  the  deltoid,  biceps,  coraco-brachialis,  and  supinator  longus 
are  affected  (the  upper  arm  type  of  Remak)  (§  396).  When  the 
muscles  of  the  inferior  extremities  are  paralysed,  the  anterior 
muscles  of  the  leg  are  generally  the  first  to  be  affected  ;  but  the 
tibialis  anticus  is  often  spared  under  such  circumstances.  In 
some  cases  all  the  muscles  of  both  upper  and  lower  extremities 
are  paralysed,  and  on  rare  occasions  the  muscles  of  the  thorax 
and  back,  those  of  phonation  and  speech,  the  intercostal  muscles 
and  even  the  diaphragm  have  been  affected.  The  sphincters 
remain  always  unaffected  in  the  paraplegic  form.  Paralysis 
of  the  muscles  of  the  glottis  has  been  observed  by  Trousseau  in 
horses  employed  in  red-lead  factories.  The  paralysed  muscles 
undergo  rapid  atrophy,  and  lose  their  faradic  contractility  before 
voluntary  power  is  completely  abolished,  while  the  reaction  of 
degeneration  appears  in  them  at  an  early  period. 

The  duration  of  lead  paralysis  is  very  variable ;  it  may  last 
for  a  period  of  weeks,  months,  or  years,  and  both  it  and  the 
colic  are  liable  to  recur  on  renewed  exposure  to  the  cause. 

Tremor  is  sometimes  observed  in  lead-poisoning.  It  is  often 
limited  to  the  upper  extremities,  and  in  aggravated  cases 
may  extend  so  as  to  become  general.  Ataxic  symptoms  have 
occasionally  been  observed,  and  are  generally  associated  with 
anaesthesia  (Raymond).  The  patients  in  lead-poisoning  suffer 
from  chronic  dyspepsia  and  occasional  attacks  of  jaundice ; 
there  is  pronounced  anaemia ;  the  arteries  undergo  various 
degenerations  ;  and  chronic  Bright's  disease,  with  its  associated 
effects  on  the  mechanism  of  the  circulation,  is  frequently 
observed.  It  is  scarcely  necessary  to  add  that  the  hemiplegia, 
which  is  apt  to  occur  from  rupture  of  a  vessel  in  the  brain 
under  these  circumstances,  must  be  distinguished  from  true 
lead  paralysis.  Women  poisoned  by  lead  suffer  from  menstrual 
disorders  and  profound  anaemia,  and,  if  bearing  children,  they 
frequently  abort  or  have  stillborn  children ;  idiocy,  imbecility, 
and  epilepsy  appear  to  be  frequently  observed  amongst  the 
children  of  workers  in  lead.  Impotency  is  said  to  occur  in 
advanced  cases. 


POST-FEBRILE  NERVOUS   DISORDERS,  959 

Psychical  Disturbances. — Before  the  outbreak  of  pronounced 
cerebral  symptoms  the  patient  often  suffers  from  headache, 
vertigo,  and  drowsiness  during  the  day  and  sleeplessness  at 
night;  or  there  may  be  a  state  of  agitation  or  complete  apathy. 
Cerebral  disturbance  sometimes  assumes  the  form  of  quiet 
delirium,  accompanied  by  hallucinations  of  sight  and  hearing, 
or  on  the  other  hand  the  delirium  may  be  furious.  But  the 
most  common  cerebral  disturbance  is  convulsions.  Sometimes 
the  loss  of  consciousness  is  not  complete  and  the  convulsions 
may  be  partial,  and  limited  to  the  muscles  of  the  face  and  of 
one  or  more  limbs ;  or  they  may  be  general  and  represented  by 
general  trembling  of  the  body.  At  other  times  the  attack 
assumes  the  form  of  eclampsia.  These  convulsions  are  gene- 
rally followed  by  a  prolonged  stage  of  unconsciousness,  with 
stertorous  breathing.  The  patient  may  be  comatose  after  a  first 
attack,  or  after  a  succession  of  attacks  quickly  following  each 
other,  and  separated  in  some  cases  by  intervals,  during  which 
there  is  furious  delirium.  The  patient  generally  recovers  from 
the  first  attack,  but  is  liable  to  die  in  subsequent  attacks. 
Apoplectiform  attacks  may  occur  in  the  later  stage  of  lead 
paralysis,  and  are  accompanied  by  paralysis  of  variable  distri- 
bution ;  inasmuch  as  the  patient  often  recovers  motor  power 
quickly,  these  attacks  cannot  always  be  due  to  haemorrhage. 

§  975.  Morbid  Anatomy. — The  morbid  anatomy  of  lead- 
poisoning  has  been  studied  by  Lanceraux,  Gombault  and 
Charcot,  Westphal,  Vulpian  and  Raymond,  Erb,  and  many 
others  ;  a  careful  paper  on  the  subject,  by  Dr.  S.  Moritz,  of 
Manchester,  has  recently  appeared  in  the  "  Journal  of  Anatomy 
and  Physiology."  The  microscopical  changes  observed  in  the 
muscles  are  more  or  less  similar  to  those  already  described 
as  occurring  in  progressive  muscular  atrophy  (§  414).  The 
most  important  changes  observed  have  been  in  the  intra- 
muscular nerve  fibres.  The  connective  tissue  is  thickened,  the 
sheath  of  the  primitive  fibres  is  also  thickened,  the  nuclei  are 
largely  developed  between  them ;  the  axis-cylinders  are  some- 
times distinctly  visible,  and  at  other  times  apparently  disappear 
(Moritz).  The  nerves,  especially  the  musculo-spiral,  have  been 
found  altered  in  various  degrees.    Kussmaul  and  Meyer  observed 


960  TOXIC,   AND  FEBRILE  AND 

sclerosis  of  the  ccBliac  and  upper  cervical  ganglia,  with  prolife- 
ration of  the  connective  tissue  and  deformity  of  the  cells. 
Vulpian  observed  vitreous  degeneration  and  atrophy  of  the 
ganglion  cells  of  the  anterior  horns  of  the  spinal  cord,  and  a 
similar  observation  has  recently  been  made  by  Monakow. 
Other  observers  have  failed  to  detect  any  changes  in  the 
spinal  cord. 

§  976.  Morbid  Physiology. — There  can  be  little  doubt  that, 
as  first  suggested  by  Duchenne,  the  muscular  disease  in  lead 
paralysis  is  secondary  to  nervous  changes.  Some  observers 
believe  that  the  disease  begins  in  the  intra-muscular  nerve 
fibres;  while  others  believe  that  the  primary  disease  is  situated 
in  the  ganglion  cells  of  the  spinal  cord.  It  is  at  least  certain 
that  the  muscles  are  affected  in  groups  according  as  they  are 
associated  in  their  actions,  and  not  according  to  the  distribution 
of  a  particular  nerve,  such  as  the  musculo-spiral.  This  mode  of 
invasion  corresponds  to  what  occurs  in  infantile  paralysis  and 
progressive  muscular  atrophy,  both  of  them  spinal  diseases, 
and  differs  from  that  of  paralysis  of  peripheral  origin.  These 
considerations  tend  to  show  that  the  paralysis  is  probably  of 
spinal  origin  (Remak). 

§  977.  Diagnosis  and  Prognosis.—  Saturnine  neuroses  are 
generally  easily  recognised  by  the  knowledge  of  the  occupation 
of  the  patient  and  the  presence  of  a  blue  line  on  the  gums. 
The  prognosis  is  at  first  favourable,  but  if  colic  have  frequently 
recurred,  or  paralysis  have  existed  for  a  long  time,  and  there  be 
much  muscular  wasting  and  cachexia,  it  becomes  gloomy, 
especially  when  the  patient  remains  exposed  to  the  poison. 

§  978.  Treatment. — Patients  whose  occupations  expose  them 
to  poisoning  by  lead  should  if  possible  seek  other  employment. 
If  this  be  not  possible,  the  patient  ought  to  be  instructed  to 
observe  great  personal  cleanliness,  to  wash  the  teeth  daily,  and 
to  rinse  the  mouth  frequently  with  cold  water.  The  use  of 
lemonade  made  with  sulphuric  acid  is  said  to  prevent  lead- 
poisoning  by  converting  the  carbonate  of  lead  in  the  stomach 
into  an  insoluble  sulphate.     The  most  important  method  used 


POST-FEBRILE  NERVOUS  DISORDERS.  ■     9G1 

for  procuring  elimination  of  the  poison  appears  to  be  the 
internal  administration  of  iodide  of  potassium,  which  is  said  to 
convert  the  insoluble  salts  of  lead  deposited  in  the  tissues  into 
a  soluble  double  salt,  capable  of  being  removed.  The  warm 
bath  may  be  used  as  an  adjunct  in  treatment ;  no  benefit 
appears  to  result  from  the  addition  of  a  soluble  sulphide  to 
the  water. 

Lead  colic  must  be  treated  on  the  same  general  principles  as 
other  forms  of  colic  with  constipation  (§  336).  The  paralysed 
muscles  must  be  subjected  to  electrical  treatment. 

(III.)    MERCUEIALISM. 

§  979.  Chronic  mercurial  poisoning  nriay  be  due  to  the 
absorption  of  mercurial  preparations  through  the  skin  or  mucous 
membrane,  or  to  the  inhalation  of  the  vapour  of  mercury.  The 
workmen  engaged  in  quicksilver  mines,  and  in  trades  in  which 
mercury  is  employed,  such  as  that  of  gilders  and  looking-glass 
makers,  are  liable  to  be  affected  by  it. 

§  980.  Symptoms, — The  symptoms  of  chronic  poisoning  by 
mercury  often  begin  by  slight  numbness  in  the  hands  or  feet. 
and  occasional  neuralgic  pains  in  certain  joints,  especially  those 
of  the  thumbs,  elbows,  feet,  and  knees.  These  sensory  dis- 
turbances are  accompanied  or  soon  followed  by  slight  tremor, 
which  may  for  some  time  remain  limited  to  the  hands  and  arms. 
The  tremor,  like  that  of  disseminated  sclerosis,  only  reveals  itself 
when  the  patient  makes  a  voluntary  effort ;  but  at  an  advanced 
period  of  the  disease  it  persists  during  repose,  and  may  even 
continue  during  sleep.  The  tremor  gradually  becomes  more 
pronounced,  and  extends  to  all  parts  of  the  muscular  system. 
The  lower  extremities  tremble,  especially  at  the  knees,  when 
the  patient  stands  or  walks,  and  the  patient  is  incapable  of 
performing  any  delicate  manipulations,  while  in  aggravated 
cases  he  may  be  unable  to  carry  a  glass  of  water  to  his  mouth, 
as  in  disseminated  sclerosis.  The  head  and  neck  are  main- 
tained in  a  state  of  constant  oscillatory  movement  when  the 
patient  is  in  the  erect  posture ;  the  lips  are  tremulous ;  the 
utterance  becomes  broken  and  indistinct ;  mastication  is 
J  J  J 


962  TOXIC,  AND  FEBRILE  AND 

rendered  difficult ;  and  even  respiration  becomes  irregular  and 
laboured.  The  muscles  of  the  eyeballs  are  said  never  to  be 
affected  in  mercurial  poisoning,  a  fact  of  great  importance  in 
distinguishing  it  from  cerebro-spinal  multiple  sclerosis.  Mus- 
cular weakness  is  associated  with  the  tremor,  but  distinct 
paralysis  does  not  occur,  and  there  is  no  loss  of  sensation. 
When  the  tremors  attain  great  intensity,  they  persist  during 
repose,  and  render  the  patient  restless  and  sleepless  at  night ; 
the  appetite  fails ;  the  pulse,  strong  and  slow  at  first,  becomes 
small,  feeble,  and  frequent ;  while  the  patient  becomes 
emaciated,  and  assumes  a  cachectic  appearance.  In  the 
advanced  stage  of  the  disease  serious  cerebral  symptoms  super- 
vene, such  as  constant  headache,  sleeplessness,  loss  of  memory, 
epilepsy,  and  coma. 

§  981.  Treatment. — The  patient  must  first  of  all  be  removed 
from  the  influence  of  mercury,  whatever  be  the  way  in  which 
he  may  be  exposed  to  it.  Iodide  of  potassium  may  be  adminis- 
tered with  the  view  of  converting  the  mercurial  compound 
already  in  the  system  into  a  soluble  double  salt.  The  affected 
muscles  are  to  be  subjected  to  local  treatment  by  galvanism. 

(IV.)    SYPHILIS   OF   THE   NERVOUS  SYSTEM. 

It  has  been  abundantly  shown  in  the  course  of  this  work  that 
syphilis  may  be  a  cause  of  almost  all  the  organic  diseases  to 
which  the  peripheral  nerves,  spinal  cord,  and  brain  are  liable. 
Syphilis,  indeed,  as  Mr.  Jonathan  Hutchinson  remarks,  mimics 
nearly  all  the  organic  diseases  of  the  nervous  system,  as  well 
as  those  of  other  organs.  Instead,  therefore,  of  attempting 
to  write  a  detailed  description  of  the  numerous  manifestations 
of  syphilis  of  the  nervous  system,  it  will  suffice  here  if  we 
recapitulate  briefly  the  anatomical  alterations  produced  by  the 
action  of  the  poison,  bring  into  prominence  the  chief  points 
which  must  be  attended  to  in  recognising  its  presence,  and 
make  a  few  remarks  on  treatment. 

§  982.  Morbid  Anatomy. — Syphilis  of  the  nervous  system 
usually  belongs  to  the  later  secondary  or  to  the  tertiary  mani- 


POST-FEBRILE   NERVOUS   DISORDERS.  9G3 

festations  of  the  disease,  although  in  rare  cases  it  may  appear 
in  the  first  few  months,  or  the  year  following  infection.  Syphi- 
litic growths  are  sometimes  developed  in  the  nervous  system  as 
many  as  twenty  or  even  thirty  years  after  the  primary  infection. 
Syphilis  of  the  nervous  system  occurs  with  greatest  frequency 
in  middle  age.  Affections  of  the  nervous  system  not  unfre- 
quently  occur  during  the  first  few  years  of  life  as  the  result  of 
the  congenital  disease. 

Syphilitic  lesions  may  be  subdivided  into  :  (1)  Primary,  or 
those  which  are  directly  due  to  the  action  of  syphilis ;  and  (2) 
Secondary  lesions,  or  those  which  are  indirect  and  remote  con- 
sequences of  it. 

(1)  Pkimart  Syphilitic  Lesions. 

(a)  Disease  of  the  Bones  and  Periosteum. — Syphilitic  exos- 
toses, periostitis,  osteitis,  and  caries  of  bones  in  the  neighbour- 
hood of  nervous  structures  may  implicate  the  latter  in  disease. 
In  this  manner  the  peripheral  nerves,  as  they  pass  through  bony 
channels,  may  be  compressed  or  otherwise  injured,  the  vertebral 
canal  may  be  narrowed  and  the  spinal  cord  pressed  upon,  and 
disease  may  be  set  up  in  the  brain  and  its  membranes  by 
syphilitic  affections  of  the  cranial  bones. 

(6)  Formation  of  Gummata. — These  have  already  been 
described  sufficiently  for  our  purpose  (§  732).  Gummata  may 
grow  in  the  dura  mater  or  pia  mater.  When  a  gumma  grows 
in  the  dura  mater  it  develops  between  its  two  layers  and 
becomes  encapsulated.  When  it  is  developed  in  the  subarach- 
noid spaceall  the  surrounding  tissues,  including  the  membranes, 
the  blood-vessels  and  nerves  which  traverse  the  space,  and  the 
substance  of  the  brain  itself,  are  involved  in  the  lesion.  The 
majority  of  cerebral  gummata  originate  from  the  subarachnoid 
space  and  pia  mater,  and  grow  towards  the  substance  of  the 
brain.  If  the  growth  be  situated  on  the  convexity  ^.nd  lateral 
surfaces  of  the  hemispheres,  the  dura  mater  becomes  so  closely 
adherent  to  the  cortex  that  the  former  cannot  be  separated 
without  producing  laceration  of  the  latter.  If  it  be  situated 
at  the  base  of  the  brain  the  dura  mater  is  less  frequently 
implicated,  and  the  new  growth  then  usually  fills  the  spaces 
around  the   chiasma   and   infundibulum,  the  interpeduncular 


964  TOXIC,   AND   FEBRILE  AND 

space,  and  the  spaces  at  the  anterior  and  posterior  borders  of 
the  pons. 

Gumraata  may  also  grow  between  the  layers  of  the  dura 
mater  or  in  the  subarachnoid  space  in  the  vertebral  canal. 
The  membranes  become  adherent  to  one  another,  and  the 
spinal  cord  is  compressed  and  gradually  destroyed  at  the  level 
of  the  growth. 

The  peripheral  nerves  may  also  be  affected  by  a  gumma 
situated  in  their  neighbourhood,  or  by  the  extension  of  the 
infiltration  into  the  substance  of  the  nerve.  The  cranial  nerves 
are  most  commonly  implicated  at  their  points  of  origin  and 
before  they  become  covered  by  a  prolongation  of  the  dura 
mater. 

(c)  Syphilitic  Infiltration.  —  The  gummatous  formation 
sometimes  forms  a  diffused  infiltration  in  the  substance  of  the 
nervous  tissues  instead  of  forming  circumscribed  tumours.  A 
layer  of  gummatous  tissue  may  in  this  manner  be  formed  in  the 
pia  mater  on  the  surface  of  the  convolutions  of  the  brain. 

(d)  Syphilitic  Sclerosis. — It  is  very  probable  that  syphilitic 
sclerosis  is  always  preceded  by  an  infiltration  of  the  nervous 
tissues  by  young  cells  similar  to  those  observed  in  the  gumma- 
tous infiltrations.  These  cells  become  infiltrated  around  the 
vessels  and  in  the  connective  tissue  septa  and  neuroglia,  and 
subsequently  undergo  partial  organisation  and  cicatricial  con- 
traction. This  process  leads  to  the  gradual  destruction  of  the 
nerve  elements,  just  as  occurs  in  ordinary  chronic  interstitial 
inflammation  of  the  brain,  spinal  cord,  and  peripheral  nerves. 

(e)  Syphilitic  Adhesion  and  Opacities. — When  the  cellular 
infiltration  occurs  in  the  membranes  and  subsequently  under- 
goes organisation  and  retractiou,  a  fibroid  tissue  is  formed  which 
renders  the  portion  affected  dense,  opaque,  and  inelastic;  adhe- 
sions form  between  the  dura  mater  and  pia  mater,  and  between 
the  latter  and  the  cortex  of  the  brain  or  the  surface  of  the 
spinal  cord.  When  the  membranes  over  the  base  of  the  skull 
and  brain  are  affected,  the  cranial  nerves  may  be  surrounded 
by  cicatricial  tissue.  When  the  pia  mater  becomes  indurated, 
the  calibre  of  the  vessels  supplied  to  the  cortex  of  the  brain  is 
liable  to  be  diminished,  and  the  nervous  tissues  are  thus  imper- 
fectly supplied  with  nourishment. 


POST-FEBRILE   NERVOUS  DISORDERS.  965 

(f)  Syphilitic  Periarterites  and  Endarterites. — It  is  probable 
that  the  adventitia  of  the  smaller  arteries  are  implicated  to  a 
greater  or  lesser  extent  in  all  the  syphilitic  processes  which 
have  been  described.  Medium  sized  vessels  may  sometimes 
be  surrounded  by  concentric  layers  of  gummatous  tissue,  which 
ultimately  compress  them  so  as  to  cause  their  partial  oblite- 
ration. A  gumma  may,  like  any  other  tumour,  during  its 
growth  compress  and  obliterate  both  arteries  and  veins  in  its 
neighbourhood.  But  the  walls  of  the  arteries  are  liable  to  be 
affected  in  syphilis  in  a  much  more  direct  manner  than  by 
any  of  the  processes  just  described.  The  substance  of  the 
walls  may  be  infiltrated  with  cells,  and  these  may  undergo 
partial  organisation  and  cicatricial  retraction,  or  form  gumma- 
tous masses.  The  infiltration  may  take  place  chiefly  into  the 
adventitia  of  the  vessel  (periarteritis)  or  between  the  intima 
and  endothelium  (endarteritis),  but  it  is  probable  that  in  most 
cases  all  the  coats  are  more  or  less  infiltrated.  When  the 
cellular  infiltration  is  diffused  throughout  all  the  coats  of  the 
vessel  and  undergoes  partial  organisation  and  cicatricial  re- 
traction, the  walls  of  the  affected  artery  become  inelastic  and 
brittle,  while  its  calibre  is  uniformly  reduced  in  size.  Wben, 
on  the  other  hand,  the  infiltration  is  more  limited,  hard  cir- 
cumscribed spots  may  be  found,  which  project  from  the  ex- 
ternal or  internal  surfaces  of  the  vessel,  distorting  it  in  various 
ways.  It  would  appear  that  distinct  gummata  may  form  in 
the  walls  of  arteries,  and  either  project  from  its  external  surface 
or  into  its  lumen,  and  in  the  latter  case  may  either  obstruct 
the  vessel  completely  or  be  washed  off  to  be  arrested  as  an 
embolus  in  one  of  the  smaller  branches. 

(2)  Secondary  Syphilitic  Lesions.^ 

The  processes  which  result  indirectly  from  syphilis  are — 
(a)  Inflammation;  (b)  Partial  ischcemia,  with  necrotic 
softening. 

(a)  Inflammation- — Syphilitic  diseases  of  the  bones  of  the 
cranium  may  set  up  suppurative  arachnitis  (Wilks  and  Moxon), 
but  the  purulent  affection  is  of  itself  not  a  syphilitic  lesion. 
Syphilitic  gummata  act  like  foreign  bodies  on  the  surrounding 
tissues,  and  consequently  the  membranes  in  its  neighbourhood 


966  TOXIC,   AND  FEBRILE  AND 

are  usually  thickened  and  adherent,  while  the  cerebral  tissue 
surrounding  it  is  maintained  in  a  state  of  irritation.  It  is  pro- 
bable that  the  thickened  layer  by  which  a  gumma  is  sometimes 
encrusted  is  formed  by  partial  organisation  of  inflammatory 
products  in  the  tissues  immediately  adjoining  the  syphilitic 
tissue.  Some  cases  reported  appear  to  show  that  the  presence 
of  a  gumma  on  the  surface  of  the  brain  may  set  up  an  acute 
attack  of  meningo-encephalitis  (Gamel).  Acute  ascending  spinal 
paralysis  is  liable  to  occur  in  syphilitic  subjects,  but  in  such 
cases  it  is  difficult  to  determine  whether  or  not  the  lesion  is  a 
primary  or  secondary  result  of  the  syphilitic  poison. 

When  once  a  sclerosis  of  nervous  tissues  is  set  up  by  a 
syphilitic  lesion,  it  is  probable  that  the  process  may  assume  a 
progressive  character  independently  of  the  syphilitic  poison. 

(6)  Partial  Ischcemia  and  Necrotic  Softening. — When  a 
portion  of  the  pia  mater  undergoes  fibroid  thickening  in 
syphilis,  the  calibre  of  the  vessels  which  pass  through  it  to 
nourish  the  subjacent  nervous  tissues  is  reduced  in  size,  and 
these  tissues  suffer  from  ansemia.  As  the  fibroid  thickening 
is  probably  always  local  in  syphilis,  the  resulting  anaemia  is 
also  local.  Much  more  important,  however,  is  the  anaemia 
caused  by  obliteration  of  vessels.  Obliteration  of  the  vessels 
may  occur  in  several  ways ;  but  occlusion  of  an  artery  by  the 
formation  of  a  thrombus  at  a  point  where  its  inner  surface 
has  been  rendered  uneven  and  its  calibre  diminished  is  by  far 
the  most  common  and  important  of  these.  Obliteration  of  an 
artery,  in  whatever  way  it  may  be  brought  about,  is  followed 
by  partial  ischsemia,  and  local  softening  in  those  portions  of  the 
brain  where  the  terminal  arteries  do  not  anastomose  with  one 
another. 

Situation  and  Mode  of  Distribution  of  Syphilitic  Lesions. 
From  what  has  already  been  said  it  will  be  seen  that  gummata 
as  a  rule  form  in  the  membranes  of  the  brain  and  spinal  cord. 
It  follows  that  the  cortex  of  the  brain  and  the  white  columns 
of  the  spinal  cord  are  especially  liable  to  be  affected  by  gum- 
mata. The  favourite  situations  of  gummata  in  the  brain  are 
the  base  and  cortex  of  the  convexity  in  the  region  of  distri- 
bution of  the  middle  and  anterior  cerebral  arteries. 

Syphilitic  thrombosis,  like  every  other  form  of  obstruction 


POST-FEBRILE   NERVOUS  DISORDERS.  967 

of  arteries,  assumes  greater  importance  when  it  occurs  in  the 
arteries  of  the  brain  than  in  those  of  other  parts  of  the  nervous 
system.  The  middle  cerebral  artery  and  its  branches  are 
particularly  liable  to  become  occluded  in  syphilis,  hence  the 
frequency  with  which  hemiplegia  with  or  without  aphasia 
occurs  in  syphilitic  subjects. 

Gummatous  growth,  whether  it  form  a  circumscribed  tumour 
or  be  infiltrated,  is  usually  more  or  less  localised,  and  con- 
sequently gives  rise  to  the  symptoms  characteristic  of  focal 
diseases  of  the  brain. 

Syphilitic  lesions  are  very  liable  to  be  multiple,  or,  in  other 
words,  to  appear  at  different  parts  of  the  nervous  system  at  the 
same  time,  so  that  the  symptoms  produced  are  such  as  those 
resulting  from  more  than  one  focus  of  disease.  When  the 
lesions  are  bilateral  they  are  seldom  symmetrically  placed,  they 
often  appear  at  different  times,  and  frequently  differ  in  kind. 
A  syphilitic  lesion  compressing  a  cranial  nerve  on  one  side  may 
be  associated  with  a  gumma  of  the  cortex  of  the  opposite  hemi- 
sphere, but  rarely  with  a  gumma  compressing  the  corresponding 
nerve  on  the  opposite  side.  A  syphilitic  lesion  of  one  of  the 
cranial  nerves  is  often  associated  with  syphilitic  thrombosis  of 
cerebral  vessels,  but  these  lesions  usually  appear  at  different 
times,  so  that  there  is  a  history  of  two  separate  attacks. 

§  983.  Diagnosis. — In  some  cases  constitutional  symptoms 
are  so  apparent  that  the  presence  of  syphilis  cannot  be  over- 
looked. If  characteristic  cutaneous  eruptions  and  ulcerations, 
osseous  defects  in  the  nose  and  palate,  be  present,  the  nature 
of  the  case  can  hardly  remain  in  doubt ;  although  it  must  not 
be  forgotten  that  persons  who  have  previously  suffered  from 
syphilis  are  also  liable  to  nervous  diseases  of  non- syphilitic 
origin.  Nervous  affections,  as  a  rule,  belong  to  the  later  mani- 
festations of  the  disease,  and  make  their  appearance  long  after 
the  more  prominent  symptoms  of  the  constitutional  disease 
have  ceased  to  exist.  Search  must  then  be  made  for  cicatrices 
on  the  genitals  or  on  the  groins,  round  pigmented  spots  on 
the  skin ;  depressed  and  irregular  cicatrices  over  the  forehead 
and  front  of  the  legs  with  the  integument  adhering  to  the  sub- 
jacent bones ;   radiated  cicatrices  on  the  mucous  membranes. 


968  TOXIC,   AND  FEBRILE  AND 

especially  of  the  mouth ;  circular  depressions  on  the  arches  of 
the  palate  or  tonsils,  which  look  as  if  a  piece  of  tissue  bad 
been  punched  out  ;  irregular  protuberances  on  the  surfaces  of 
the  bones ;  a  moderate  degree  of,  but  hard,  swelling  of  the 
occipital,  cervical,  or  cubital  lymphatic  glands;  and  enlargement 
and  knobby  induration  or  atrophy  of  one  testicle.  An  inquiry 
into  the  history  of  a  case  may  throw  great  light  upon  its  nature. 
If  the  patient  be  a  man,  it  may  be  asked  whether  he  has  ever 
suffered  from  syphilitic  infection.  In  the  case  of  a  married 
woman,  valuable  information  may  be  obtained  by  ascertaining 
whether  or  not  she  has  had  miscarriages,  if  some  of  her  children 
were  still-born  or  died  soon  after  birth,  or  whether  they  mani- 
fest any  of  the  characteristic  symptoms  of  congenital  syphilis. 

(1)  Syphilitic  Lesions  of  the  Peripheral  Nerves. — Syphilitic 
lesions  of  peripheral  nerves,  like  all  other  similar  lesions,  are 
manifested  by  symptoms  of  irritation,  as  hypersesthesia,  neu- 
ralgia, and  spasm ;  followed  by  symptoms  of  depression,  as 
simple  anaesthesia,  anaesthesia  dolorosa,  or  paralysis  in  the 
region  of  distribution  of  the  affected  nerve,  the  symptoms  of 
depression  being  much  more  important  and  frequent  than  those 
of  irritation.  Syphilitic  disease  of  the  peripheral  spinal  nerves 
may  occur ;  but  the  cranial  nerves  are  much  more  frequently 
affected.  In  syphilitic  disease  of  the  motor  nerves  the  paralysis 
is  sometimes  limited  to  a  single  muscle ;  while  the  other 
muscles  supplied  by  the  same  nerve  remain  unaffected,  or 
manifest  only  a  slight  degree  of  weakness.  The  oculo-motorius 
appears  to  be  the  most  frequently  affected  of  the  cerebral 
nerves,  and  ptosis  generally  precedes  paralysis  of  the  recti 
muscles.  When,  therefore,  ptosis  is  suddenly  developed  without 
any  apparent  cause,  syphilis  should  be  suspected.  It  must 
be  remembered  that  paralysis  of  one  or  more  of  the  ocular 
muscles  is  liable  to  appear  in  the  early  stage  of  locomotor 
ataxy,  and  cases  presenting  these  symptoms  should,  therefore, 
be  carefully  examined  to  see  whether  or  not  lancinating  pains, 
absence  of  the  deep  reflexes,  or  ataxia  be  present. 

If  double  optic  neuritis,  paroxysmal  vomiting,  and  headache 
be  present  along  with  the  paralysis  of  the  third  nerve,  the  latter 
is  caused  by  the  pressure  of  a  tumour  on  the  nerve  at  the  base 
of  the  brain,  but  even  then  the  tumour  may  be  of  syphilitic 


POST-FEBRILE   NERVOUS   DISORDERS.  969 

origin.  Aneurism  of  one  of  the  arteries  at  the  base  of  the 
brain  may  give  rise  to  similar  symptoms,  but  it  is  frequently 
associated  with  vegetations  on  the  cardiac  valves  (Ogle,  Church). 
Basilar  meningitis  may  also  paralyse  the  third  nerve ;  the 
acute  form  of  this  disease  bears  no  resemblance  to  syphilis,  but 
the  chronic  form  of  meningitis  may  be  indistinguishable  from 
it,  except  by  the  fact  that  treatment  is  not  followed  by  favour- 
able results.  The  sixth  nerve  is  also  frequently  affected  in 
syphilis,  either  separately  or  along  w^ith  the  fifth  or  seventh 
nerve  on  the  same  side.  Syphilitic  disease  of  the  fifth  is  not 
unfrequent,  and  the  nerve  may  be  affected  at  its  origin,  at  the 
Gasserian  ganglion,  or  in  its  separate  divisions.  Disease  of  this 
nerve  first  declares  itself  by  neuralgic  pains  in  the  region  of 
its  distribution,  which  are  liable  to  nocturnal  exacerbations, 
and  occasionally  anaesthesia  may  be  associated  with  the  pain. 
The  motor  root  of  the  nerve  is  often  affected,  and  then  there  is 
masticatory  paralysis  with  atrophy  and  the  reaction  of  degenera- 
tion in  the  affected  muscles.  The  paralysis  is  sometimes  preceded 
by  spasmodic  movements  of  the  affected  muscles.  When  the 
Gasserian  ganglion  is  implicated  there  is  lachrymation  and 
neuroparalytic  ophthalmia.  Syphilitic  affections  of  the  fifth 
nerve  are  probably  never  bilateral,  and  if  both  be  paralysed  by 
the  pressure  of  a  tumour  at  the  base  of  the  brain,  the  growth 
is  likely  to  be  cancer  (Hutchinson). 

The  seventh  nerve  is,  with  the  exception  of  the  motor  nerves 
of  the  eyeball,  more  frequently  affected  in  syphilis  than  any 
other  cranial  nerve.  The  paralysis  may  affect  all  the  branches 
of  the  nerve,  or,  contrary  to  what  occurs  in  central  paralysis  of 
the  facial,  the  muscles  about  the  eye  may  be  the  first  to  become 
paralysed.  The  hypoglossal  nerve  is  probably  never  subject  to 
isolated  paralysis  in  syphilis.  The  optic  nerves,  chiasma,  or 
tracts  may  be  the  first  to  suffer,  and  unilateral  amaurosis  with 
descending  neuro-retinitis,  or  different  forms  of  hemiopia  may 
occur  according  to  the  situation  of  the  lesion.  Some  cases  of 
amblyopia  or  amaurosis  have  been  recorded  in  which  no 
lesion  could  be  detected  by  ophthalmoscopic  examination, 
but  which  were  cured  by  antisyphilitic  treatment.  Various 
forms  of  neuralgia  are  held  to  be  of  syphilitic  origin  in  the 
absence  of  anatomical  proof,  because  they  occur  in  syphilitic 


970  TOXIC,   AND   FEBRILE  AND 

subjects  and  yield  to  antisyphilitic  treatment.  The  most  fre- 
quent of  these  are  sciatica,  occipital  neuralgia,  and  neuralgias 
of  the  testicle,  scrotum,  and  various  viscera, 

(2)  Syphilitic  Lesions  of  the  Spinal  Cord  and  its  Mem- 
branes.— These  form  late  manifestations  of  the  disease,  and,  as 
a  rule,  marked  cachexia  is  present  before  their  appearance. 
The  nervous  symptoms  are  generally  preceded  by  general 
languor  and  a  feeling  of  debility;  after  a  time  symptoms  of 
sensory  irritation  set  in,  which  may  last  for  months  without 
paralysis.  Pains,  increased  by  pressure,  are  sometimes  situated 
at  a  fixed  spot,  over  the  vertebral  column,  in  the  cervical,  lumbar, 
or  sacral  region.  At  other  times  they  are  situated  in  the  ex- 
tremities; at  first  limited  to  an  arm  or  leg,  but  later  involving 
the  other  limbs.  The  pains  are  more  rheumatic  than  neu- 
ralgic in  character,  and  are  subject  to  great  variations  in 
duration  and  intensity  (Heubner).  The  patient  often  complains 
of  par8esthesia3,  such  as  formication,  tingling,  and  numbness  in 
the  affected  extremity. 

After  a  time  motor  disturbances  appear  in  the  form  of  rigidity 
and  temporary  spasms  of  groups  of  muscles  or  an  extremity. 
The  symptoms  are  liable  to  great  fluctuations,  and  may  entirely 
disappear  for  a  time,  the  free  intervals  being  sometimes  of 
several  months'  duration.  Sooner  or  later,  however,  the  symp- 
toms of  irritation  give  place  to  those  of  paralysis.  The  patient 
complains  of  increasing  weakness  in  one  leg  or  in  both  the  leg 
and  arm  of  the  same  side  if  the  lesion  be  situated  in  the  cer- 
vical region,  and  in  a  short  time  complete  paralysis  is  developed. 
Before  long  the  opposite  side  of  the  body  is  affected,  and  the 
paraplegia  becomes  complete.  The  accompanying  disturbances 
of  sensibility  do  not  increase  in  corresponding  ratio  as  they  do 
in  myelitis  or  other  tumours  of  the  cord.  The  extent  of  the 
paralysis  will  depend  upon  the  seat  of  the  lesion.  When  the 
lumbar  region  is  affected  both  lower  extremities  will  be 
paralysed,  but  one  usually  to  a  greater  extent  than  the  other, 
and  the  sphincters  will  also  be  involved  in  the  paralysis. 

After  a  time  the  symptoms  remain  stationary  for  a  consider- 
able period,  and  the  patient  is  confiQed  to  bed  for  weeks  or 
even  months.  If  energetic  treatment  be  adopted,  the  case  may 
slowly  improve  and  terminate  in  comparative  recovery,  the 


POST-FEBRILE  NERVOUS  DISORDERS.  971 

most  favourable  cases  being  those  in  which  the  morbid  process 
is  limited  to  the  lowest  part  of  the  cord. 

Improvement  begins  in  the  less  affected  extremity,  which 
after  a  time  completely  regains  its  motor  power ;  but,  although 
the  other  extremity  improves,  a  certain  degree  of  motor  weak- 
ness persists.  When  the  sphincters  are  affected,  bed-sores  and 
cystitis  with  their  usual  deleterious  consequences  are  apt  to 
develop. 

When  the  cervical  region  is  implicated,  and  especially  the 
upper  portion,  the  prognosis  is  very  grave,  a  condition  of  general 
paralysis  being  rapidly  developed. 

But  even  aggravated  cases  may  improve  under  energetic 
antisyphilitic  treatment,  although  the  spinal  cord  remains  to  a 
greater  or  lesser  extent  permanently  diseased.  If  the  syphilitic 
lesion  have  extended  from  the  pia  mater  to  the  lateral  columns  a 
spastic  paralysis,  resembling  more  or  less  that  of  primary  lateral 
sclerosis,  is  developed ;  while  locomotor  ataxia  is  simulated  if 
the  lesion  be  limited  to  the  posterior  columns.  In  the  above 
cases  the  syphilitic  lesion  consists  of  the  formation  of  a  gum- 
matous tissue,  either  in  the  form  of  a  more  or  less  circumscribed 
tumour  or  diffused  infiltration  into  the  spinal  cord ;  at  other 
times  the  lesion  appears  to  assume  the  form  of  a  chronic 
degeneration  or  sclerosis  from  the  commencement.  It  is 
probable  that  about  half  of  the  cases  of  locomotor  ataxia  are 
of  syphilitic  origin  (Buzzard,  Gowers,  Erb),  and  in  most  of  these 
the  lesion  is  probably  from  the  first  a  chronic  degeneration. 
The  grey  matter  appears  to  be  primarily  affected  at  other  times. 
Progressive  muscular  atrophy  is  probably  sometimes  of  syphilitic 
origin,  while  labio-glosso-laryngeal  paralysis  is  frequently  and 
exophthalmoplegia  externa  is  said  to  be  always  of  syphilitic 
origin.  A  case  came  under  my  own  observation  in  which  the 
symptoms  of  acute  spinal  paralysis  of  adults  occurred  in  a 
man  at  the  age  of  23,  while  he  was  suffering  from  secondary 
symptoms.  He  was  47  years  of  age  when  I  saw  him,  and 
the  symptoms  present  were  slight  ptosis,  paralysis  of  the 
superior  rectus,  and  comparative  dilatation  and  sluggish  move- 
ment of  the  pupil  of  the  right  eye,  a  slight '  degree  of  atrophy 
of  the  right  half  of  the  orbicularis  oris,  paralysis  with  decided 
atrophy  of  the  muscles  of  the  right  half  of  the  tongue,  and 


972  TOXIC,   AND   FEBRILE   AND 

complete  paralysis  and  atrophy  with  loss  of  the  electric  con- 
tractility of  all  the  muscles  which  produce  dorsal  flexion  of 
the  foot.  All  sensory  disturbances  were  absent.  The  presence 
of  multiple  lesions  in  this  case  points  to  its  syphilitic  origin. 
It  must  also  be  remembered  that  acute  ascending  paralysis  is 
apt  to  become  developed  in  syphilitic  subjects;  but  no  lesion 
which  can  be  regarded  as  characteristic  of  syphilis  has  been 
discovered  in  the  spinal  cords  of  such  cases. 

(3)  Syphilitic  Lesions  of  the  Brain  and  its  Membranes. — 
The  outbreak  of  cerebral  syphilis  is  generally  preceded  by 
premonitory  symptoms.  Headache  is  the  most  constant  and 
important  of  these,  and  it  may  precede  more  pronounced  cerebral 
symptoms  by  days,  months,  or  even  years.  It  occurs  in 
paroxysms  which  are  sometimes  so  intense  as  to  be  almost 
insupportable.  The  pain  is  seldom  diffused  over  the  whole 
head,  but  generally  occupies  the  lateral,  anterior,  or  posterior 
half,  or  is  limited  to  a  very  circumscribed  region  which  is  tender 
to  pressure.  The  headache  is  liable  to  nocturnal  exacerbations 
of  great  severity,  while  there  is  a  remission  or  complete  inter- 
mission in  the  morning ;  it  may  entirely  disappear  for  weeks  or 
months,  without  treatment,  and  afterwards  recur  with  great 
severity.  Sleeplessness  is  another  important  symptom  of  this 
early  stage ;  it  is  sometimes  but  not  always  the  result  of  the 
headache,  and  may  continue  during  the  remissions  of  the 
latter.  Other  premonitory  symptoms  of  less  constancy  and 
importance  are,  attacks  of  dizziness,  feeling  of  fainting, 
numbness  in  the  head,  shooting  pains  in  the  extremities, 
general  discomfort,  slight  loss  of  memory,  mental  confusion, 
great  excitability  of  manner,  and  irritability  of  temper.  Some 
of  these  symptoms  probably  occur  in  every  case,  but  they  may 
sometimes  be  so  sli'ght  and  transient  that  the  patient  does  not 
complain  of  them  unless  questioned. 

The  purely  nervous  symptoms  depend  upon  the  nature  and 
situation  of  the  lesion,  and  may  be  divided  into  the  following 
varieties :  (a)  Symptoms  caused  by  the  presence  of  a  gumma 
within  the  cranium,  (6)  those  caused  by  occlusion  of  one  of  the 
arteries  of  the  brain,  and  (c)  those  caused  by  chronic  degenera- 
tive changes. 

(a)  Gumma. — If  the  gummatous  tissue  form   a   distinctly 


POST-FEBRILE  NERVOUS  DISORDERS.  973 

circumscribed  growth,  it  gives  rise  to  double  optic  neuritis,  and 
the  other  symptoms  which  characterise  intracranial  tumours. 
If  the  syphilitic  tissue  be  infiltrated,  the  symptoms  of  a  focal 
disease  are  probably  present,  but  without  double  optic  neuritis. 
We  have  already  seen  that  syphilitic  growths  are  situated  near 
the  surface  of  the  brain.  When  the  lesion  is  situated  at  the 
base  of  the  brain,  the  most  prominent  phenomena  will  be  those 
of  pressure  upon  the  cranial  nerves,  which  have  already  been 
considered.  When,  again,  the  growth  is  situated  on  the  con- 
vexity, the  most  prominent  symptoms  are  due  to  implication  of 
the  cortex  of  the  brain.  The  primary  lesion  of  the  cortex  is 
generally  irritative ;  but,  as  the  growth  enlarges,  part  of  the 
cortex  is  injured,  so  that  a  destroying  lesion  is  superadded  to 
the  irritative  or  discharging  one.  If  the  lesion  be  situated  in 
the  area  of  distribution  of  the  Sylvian  artery,  the  symptoms 
begin  by  a  unilateral  epileptiform  attack,  usually  followed 
by  some  degree  of  paralysis  of  the  muscles  first  implicated  in 
the  convulsions.  •These  epileptiform  convulsions  (Jacksonian 
Epilepsy)  have  been  already  fully  considered,  and  it  is  un- 
necessary to  describe  them  further.  If  the  syphilitic  lesion  be 
situated  in  the  region  of  the  anterior  cerebral  artery,  then 
psychical  disturbances  predominate,  consisting  of  a  drowsy 
delirium  followed  by  a  somnolent  condition,  and  more  or  less 
coma. 

(b)  Neurotic  Softening. — Occlusion  of  a  cerebral  vessel,  as 
the  result  of  syphilis,  produces  all  the  usual  symptoms  of  that 
accident  from  any  other  cause.  When  a  vessel  is  occluded, 
unless  collateral  circulation  be  soon  established,  a  focus  of 
softening  results,  which  produces  the  usual  phenomena  of  focal 
disease.  If  the  vessels  of  the  lenticular  nucleus  are  occluded, 
hemiplegia  may  be  produced,  but  the  patient  recovers ;  occlu- 
sion of  Broca's  artery  causes  ataxic  aphasia,  and  of  the  posterior 
branch  of  the  Sylvian  artery,  amnesic  aphasia ;  while  softening 
in  the  area  of  the  anterior  cerebral  artery  gives  rise  to  loss  of 
memory,  confusion  of  ideas,  and  other  psychical  disturbances. 
What  distinguishes  syphilitic  thrombosis  from  other  forms  of 
occlusion  of  vessels  is  that  it  often  occurs  at  a  comparatively 
early  period  of  life,  when  atheroma  of  the  arteries  is  not  usually 
present,  and  in  the  absence  of  all  the  conditions  which  give 


974  TOXIC,  AND  FEBRILE   AND 

rise  to  embolism  or  haemorrhage.  Syphilitic  thrombosis  is 
besides  often  associated  with  peripheral  paralysis  of  one  of 
the  cranial  nerves.  It  must  be  remembered  that  unilateral 
amaurosis  may  occur  in  syphilis  from  thrombosis  of  the  central 
artery  of  the  retina. 

(c)  Chronic  Degenerative  Changes. — In  cases  of  this  kind 
the  course  of  the  disease  is  more  or  less  like  that  of  general 
paralysis  of  the  insane.  The  symptoms  begin  insidiously,  with 
feelings  of  general  uneasiness  and  discomfort,  the  health  suffers, 
there  is  an  unusual  degree  of  mental  irritability,  or  great 
mental  activity  interrupted  by  attacks  of  confusion  of  ideas. 
The  patient  commonly  has  ideas  of  grandeur,  and  may  indulge 
in  extravagance  much  beyond  his  means.  In  cases  of  the  kind 
the  syphilitic  affection  is  liable  to  manifest  itself  by  a  fresh 
attack  of  constitutional  symptoms  in  the  throat,  nose,  or  hands. 
After  a  time  new  symptoms  make  their  appearance ;  the  patient 
is  easily  fatigued,  he  is  no  longer  capable  of  undergoing  sus- 
tained exertion,  the  gait  is  staggering,  and  His  movements  are 
uncertain  and  hesitating.  The  patient  complains  of  numbness, 
formication,  and  shooting  pains  in  one  of  his  limbs,  the  speech 
is  hesitating,  and  stammering,  the  tongue  trembles,  and  memory 
and  intelligence  decrease  gradually  and  steadily.  Various  forms 
of  paralysis  now  make  their  appearance  ;  the  gait  is  ataxic ;  the 
writing  is  irregular  and  ultimately  becomes  illegible ;  and  after 
a  variable  period  of  years  the  patient  dies  with  cystitis,  bed- 
sores and  their  consequences,  unless  carried  off  by  some  inter- 
current affection. 

§  984.  Treatment.  —  The  treatment  of  syphilitic  nervous 
affections  must  be  prompt  and  energetic,  inasmuch  as  delay  may 
lead  to  irreparable  injury  being  done  to  the  part  affected.  If 
the  presence  of  a  gumma  be  suspected,  the  iodide  of  potassium 
should  be  at  once  administered  in  doses  of  a  scruple  to  half  a 
drachm  three  times  daily.  The  iodide  may  from  the  first  be 
combined  with  mercurial  treatment,  or  the  administration  of 
the  latter  may  be  deferred  until  the  former  has  had  time  to 
dissipate  the  gumma.  The  iodide,  however,  should  never  be 
trusted  alone,  as  the  lesion  is  likely  to  recur  in  some  other 
situation  within  a  period  of  a  few  months,  unless  mercury  be 


POST-FEBRILE   NERVOUS   DISORDERS.  975 

administered.  In  aggravated  cases  from  three  to  four  scruples 
of  mercurial  ointment  should  be  rubbed  daily  over  the  lower 
and  upper  extremities,  the  abdomen,  and  back  during  the  first 
fourteen  days.  If  improvement  be  manifested  at  the  end  of 
this  time,  the  same  quantity  should  be  rubbed  in  every  other 
day  for  several  weeks,  and  then  half  the  quantity  at  the  same 
intervals  for  several  additional  weeks.  The  mouth  and  teeth 
should  be  frequently  washed  during  this  treatment,  in  order  to 
prevent  salivation.  In  milder  cases  the  internal  administration 
of  mercury  is  more  convenient  than  the  inunction,  and  equally 
efficacious,  and  no  preparation  can  answer  the  purpose  better 
than  the  bichloride. 

In  syphilitic  epilepsy  the  bromide  of  potassium  may  be  com- 
bined with  the  iodide,  and  to  allay  neuralgic  and  other  pains 
morphia  must  be  had  recourse  to.  In  the  treatment  of  painful 
affections  of  the  peripheral  nerves  chloral  may,  according  to 
Dowse,  be  added  to  the  solution  of  the  iodide  of  potassium. 

(V.)    FEBEILE    AND    POST-FEBEILE    NEUROSES. 

§  985.  Numerous  nervous  disturbances  are  liable  to  occur  in 
the  course  of  or  during  convalescence  from  febrile  diseases. 
The  diseases  which  are  most  commonly  accompanied  or  followed 
by  nervous  disorders  are  typhoid  fever,  the  acute  exanthemata, 
acute  dysentery,  pneumonia  and  pleurisy,  nephritis  and  cystitis, 
acute  rheumatism,  intermittent  fever,  and,  above  all,  diphtheria. 
The  nervous  disorders  of  febrile  disease  are  generally  the  same 
as  those  which  arise  from  other  causes,  and  may  affect  the 
peripheral  nerves,  the  spinal  cord,  or  the  brain. 

(1)  Neurosis  of  Typhoid  Fever. — During  the  first  stage  of 
typhoid  the  patient  may  complain  of  cutaneous  hyperesthesia, 
which  may  involve  a  considerable  portion  of  the  limbs  and 
trunk.  Hypersesthesia  and  neuralgiform  pains  are  often  pre- 
sent in  the  muscles  of  the  limbs,  neck,  thorax,  and  abdomen. 
These  pains  are  frequently  associated  with  cutaneous  hyperees- 
thesia ;  they  cause  severe  suffering  to  the  patient,  and  all 
movements  tending  to  stretch  the  affected  muscles  are  avoided. 
Anaesthesia,  either  complete  or  partial,  and  of  variable  distribu- 
tion, may  appear  in  the  course  of  the  fever,  and  may  be  present 


976  TOXIC,   AND   FEBRILE  AND 

as  ancestkesia  dolorosa.  It  may  occur  during  convalescence, 
and  prove  rebellious  to  treatment.  Neuralgic  pains  often 
occur  during  the  first  week  of  the  fever  in  the  region  of  the 
occipital,  supra-orbital,  or  other  nerve ;  during  convalescence 
similar  pains  are  apt  to  appear  in  the  loias  and  along  the 
vertebral  column,  or  in  the  region  of  distribution  of  one  of  the 
branches  of  the  brachial,  lumbar,  or  sacral  plexuses. 

The  muscles  supplied  by  certain  nerves  may  be  paralysed  in 
the  course  of  typhoid  fever.  A  case  is  reported  by  Eisenlohr 
in  which  the  muscles  of  the  left  lower  extremities  supplied  by 
the  tibial  and  peroneal  nerves  were  paralysed  during  a  relapse 
of  typhoid  fever.  Electrical  examination  of  the  affected  muscles 
revealed  the  reaction  of  degeneration  in  them.  Paralysis  of 
the  abductors  of  the  glottis  has  been  known  to  occur  during 
convalescence  and  to  render  the  operation  of  tracheotomy 
necessary.  Paralysis  sometimes  assumes  the  paraplegic  form. 
Cormack  records  a  case  in  which  paraplegia  gradually  super- 
vened about  the  seventh  week  from  the  beginning  of  an 
attack  of  typhoid  fever.  The  patient  also  had  paralysis  of  the 
external  rectus  muscle  of  the  left  eye,  and  retention  of  urine, 
but  ultimately  recovered. 

The  central  forms  of  myelitis  are  liable  to  supervene  in  the 
course  of  typhoid  fever.  Leudet  observed  a  case  in  which 
acute  ascending  paralysis  developed  during  convalescence  from 
a  mild  attack,  and  proved  fatal  in  six  days.  Another  case  is 
reported  by  Yulpian  in  which  symptoms  of  acute  myelitis 
supervened  during  convalescence  from  typhoid  fever,  and 
although  the  patient  ultimately  recovered,  paraplegia  and 
atrophy  of  the  muscles  persisted  for  a  long  time.  Progressive 
muscular  atrophy,  ataxia,  multiple  sclerosis,  and  other  chronic 
affections  of  the  spinal  cord  may  become  established  during 
convalescence  from  typhoid  fever. 

Cerebral  disturbances  not  unfrequently  occur  during  or  sub- 
sequently to  an  attack  of  typhoid  fever.  A  case  of  temporary 
aphasia  is  mentioned  by  Trousseau  as  occurring  during  con- 
valescence from  typhoid.  Temporary  hemiplegia  may  super- 
vene after  an  attack  of  typhoid.  In  other  cases  there  may  be 
aphasia,  delirium  of  various  forms,  or  acute  insanity. 

(2)  Nervous  Disorders  of  the  Acute  Exanthemata. — The 


POST-FEBRILE   NERVOUS   DISORDERS.  977 

rachialgia  which  ushers  in  an  attack  of  smallpox  is  no  doubt  of 
nervous  origin ;  it  is  often  accompanied  by  considerable  weak- 
ness or  even  complete  paralysis  of  the  lower  extremities,  the 
bladder  being  sometimes  involved  in  the  paralysis.  The 
paralytic  phenomena  generally  disappear  with  the  rachialgia, 
but  loss  of  motor  power  of  a  more  durable  character  may 
supervene  during  convalescence.  The  paralysis  is  limited  to 
certain  groups  of  muscles  or  to  one  of  the  extremities,  or  may 
assume  the  form  of  paraplegia.  Loss  of  motor  power  is  often 
associated  with  sensory  disturbances,  and  the  affected  muscles 
may  undergo  atrophy  or  contracture.  Hemiplegia  with  aphasia 
or  other  severe  cerebral  symptoms  may  complicate  variola 
(Rosenthal).  Rubeola,  scarlet  fever,  and  erysipelas  may  be 
accompanied  or  followed  by  local  or  general  paralysis,  or  hemi- 
plegia with  persistent  aphasia.  Infantile  paralysis  is  very  liable 
to  occur  in  the  course  of  the  acute  exanthemata, 

DipJitheritic  Nervous  Disorders.  —  Paralysis  occurs  after 
diphtheria  probably  more  frequently  than  after  all  the  other 
acute  diseases  together.  An  interval  of  several  days  or  weeks 
may  elapse  between  the  termination  of  the  general  disease 
and  the  appearance  of  the  paralytic  phenomena.  Diphtheritic 
paralysis  almost  invariably  begins  in  the  muscles  of  the  soft 
palate  and  pharynx;  it  is  associated  with  anaesthesia  of  the 
affected  parts  and  loss  of  faradic  contractility  in  the  muscles 
implicated.  Motor  paralysis  is  sometimes  preceded  by  violent 
vomiting  and  retardation  of  the  pulse,  while  death  appears  to  be 
sometimes  caused  by  paralysis  of  respiration  (Landouzy).  These 
phenomena  seem  to  be  the  result  of  a  primary  irritation  followed 
by  paralysis  of  the  vagus,  and  it  is  unnecessary  to  describe 
them  in  detail  (§§  270  to  282).  I  have  known  glycosuria  to 
occur  during  convalescence  from  diphtheria,  but  I  am  unable 
to  state  whether  the  symptom  was  transitory  or  permanent. 
Paralysis  may  invade  various  other  muscles,  such  as  those  of 
the  vocal  cords,  tongue,  and  eyeballs,  the  muscles  of  accom- 
modation being  specially  liable  to  be  affected.  The  paralysis 
extends  to  the  muscles  of  the  trunk  and  extremities  ;  it  is 
rarely  complete,  but  the  bladder  and  rectum  may  be  involved ; 
Trousseau  observed  impotence  in  young  men,  lasting  several 
weeks   or   months.      Death   has   been  known   to   result  from 

KKK 


978  TOXIC,  AND  FEBRILE  AND 

paralysis  of  the  diaphragm.  The  sensory  disturbances  consist 
of  hyperaesthesia  at  first,  followed  by  numbness  and  anaesthesia. 
The  sense  of  taste,  smell,  or  hearing  may  occasionally  be 
affected,  and  disturbances  of  vision  are  frequent.  The  disorders 
of  sight  may  be  caused  by  paralysis  of  some  of  the  external  or 
internal  muscles  of  the  eye ;  there  may  be  complete  amaurosis, 
which  may  continue  during  several  weeks,  no  appreciable 
changes  being  present  in  the  discs. 

(3)  Paralysis  of  Acute  Febrile  Diseases. — Acute  rheumatism 
is  sometimes  followed  by  a  local  paralysis  in  the  region  of  distri- 
bution of  one  of  the  peripheral  nerves.  Pneumonia  and  pleurisy 
are  sometimes  complicated  by  paraplegia  or  hemiplegia,  but  it  is 
doubtful  whether  there  is  anything  more  than  an  accidental 
connection  between  the  local  disease  and  the  nervous  disorders. 
The  forms  of  paralysis  termed  reflex  have  already  been  con- 
sidered. 

(4)  Nervous  Disorders  of  Intermittent  Fever. — Paralysis 
sometimes  appears  suddenly  during  the  febrile  paroxysm,  and 
ceases  suddenly  with  it ;  at  other  times  it  constitutes  the  only, 
evidence  of  the  presence  of  malarial  poisoning  (pernicious  para- 
lytic fever),  and  in  other  cases  it  assumes  a  chronic  form,  and  is 
associated  with  great  cachexia.  Of  the  forms  of  paralysis  which 
occur  suddenly,  hemiplegia  with  aphasia  is  by  far  the  most 
usual.  In  the  pernicious  paralytic  variety  paraplegia,  with 
partial  anaesthesia  and  disturbances  of  sight  and  hearing,  is 
sometimes  found  associated  with  aphasia  (Vincent). 

§  986.  Morbid  Anatomy  and  Physiology. — The  changes 
which  the  muscles  undergo  in  acute  diseases  have  been  carefully 
studied  by  Hay  em,  but  this  subject  is  much  too  wide  to  be 
discussed  here.  The  local  paralyses  associated  with  anaesthesia 
occurring  after  acute  diseases  are  doubtless  of  peripheral  origin, 
and  are  probably  caused  by  neuritis.  Even  in  paraplegia  the 
disease  in  the  spinal  cord  is  supposed  by  some  authors  to  be 
secondary  to  that  of  the  peripheral  nerves,  and  the  result  of  an 
ascending  neuritis.  In  diphtheritic  paralysis  Charcot  and  Yul- 
pian  observed  degeneration  of  the  motor  nerves  of  the  velum 
palati.     Buhl  states  that  there  is  a  nuclear  exudation  into  the 


POST-FEBRILE   NERVOUS   DISORDERS.  979 

sheaths  of  the  paralysed  nerves  similar  to  the  diphtheritic 
exudation  occurring  into  the  connective  and  mucous  tissues. 
Pierrot  observed  spots  of  false  membrane  on  the  spinal  cord 
and  medulla  oblongata,  associated  with  perineuritis  of  the 
roots  of  the  corresponding  nerves.  Vulpian  observed  slight 
changes  in  the  ganglion  cells  of  the  anterior  horns  in  two  cases, 
but  found  nothing  abnormal  in  a  third.  Dejerine  found 
neuritis  of  the  anterior  roots  and  of  the  intra-muscular  nerves, 
along  with  slight  alterations  in  the  grey  substance  of  tiie 
cord  ;  the  posterior  roots  and  white  substances  were  normal. 
Westphal  found  spots  of  softening  disseminated  throughout 
the  spinal  cord  in  a  case  of  paraplegia  occurring  in  the  course 
of  smallpox.  It  is  manifest  that  various  and  manifold  lesions 
may  be  found  in  febrile  and  post-febrile  nervous  disorders 
affecting  peripheral  nerves,  spinal  cord,  or  brain.  The  nature 
of  these  lesions  is  probably  very  various.  Sometimes  the  lesion 
consists  of  hypersemia,  at  other  times  of  anaemia,  either  general, 
or  partial  from  occlusion  of  vessels,  or  it  may  be  inflammatory 
or  degenerative  from  the  first. 

§  987.  Diagnosis  and  Prognosis. — That  a  nervous  disorder 
has  occurred  during  the  course  or  shortly  after  an  acute  disease 
is  rendered  evident  by  the  history  of  the  case.  The  chief 
problem  of  diagnosis  then  is  to  determine  whether  or  not 
the  lesion  be  functional  or  organic,  or  localised  in  the  peripheral 
nerves,  spinal  cord,  brain,  or  sympathetic  system.  In  order  to 
determine  the  latter  question,  it  is  necessary  to  possess  an  accu- 
rate knowledge  of  all  the  diseases,  especially  all  the  forms  of 
paralysis,  to  which  the  nervous  system  is  liable.  No  number 
of  special  diagnostic  rules  will  supply  the  place  of  this  know- 
ledge, and  such  rules  are  superfluous  to  those  possessing  it. 
It  is  scarcely  necessary  to  remind  the  reader  of  the  value  of 
electrical  examination  of  the  paralysed  nerves  and  muscles  in 
determining  whether  the  paralysis  be  of  peripheral,  spinal,  or 
cerebral  origin. 

The  prognosis  is,  as  a  rule,  favourable  in  the  nervous  disorders 
occurring  in  connection  with  acute  diseases.  In  diphtheritic 
paralysis  recovery  usually  takes  place  in  some  weeks,  bub  in 
severe  cases  it  may  be  delayed  for  six  months  and  upwards.  The 


980  FEBRILE  AND  POST-FEBRILE  DISORDERS, 

severity  of  the  primary  diphtheritic  attack  bears  no  proportion 
to  the  intensity  and  duration  of  the  subsequent  paralysis. 

§  988.  Treatment. — The  treatment  must  vary  according  to 
the  nature  of  the  lesion  and  other  circumstances.  If  there 
be  evidence  of  hypersemia  of  the  spinal  cord  or  brain,  cold 
application  should  be  employed.  As  a  rule,  however,  tonic  and 
stimulating  treatment  is  required.  If  there  be  no  organic 
disease  strychnia  is  indicated.  The  best  results  are  obtained 
from  electrical  treatment,  hydrotherapeutics,  and  change  of  air 
and  scene. 


I 


981 


INDEX. 


PAGE. 

Abdominal  muscles,  paralysis  of     . .     .  .i.  49S 
Abdominal  portion  of  the  sympathetic, 

diseases  of i.  585 

Abducens  nerve,  deep  origin  and  surface 

attachments  of i.  287 

Abducens  nerve,  paralysis  of i.  357 

Abscess,  chronic,  of  the  brain         . .     . .  731 

primary      731 

symptoms  of  the  latent  period  731 
symptoms    of    the    terminal 

period             732 

secondary 734 

varieties      734 

morbid  anatomy       736 

Achilles-tendon  reflex        i.  150 

Achromatopsia     i.  3:i0 

Acoustic  nerve,  diseases  of       i.  334 

Acoustic  nuclei 49 

Action,  automatic       76 

reBex        75 

voluntary         70 

Active  cerebral  congestion        693 

Acute  atrophic  spinal  paralysis      . .     . .  105 

definition,  history,  etiology..     ..  105 

infantile          106 

of  adults 116 

symptoms         106,  116 

course         117 

morbid  anatomy 118 

localisation    in    the    anterior 

horns       127 

morbid  physiology 129 

diagnosis 131 

prognosis 132 

treatment 133 

.\cute  ascending  paralysis        264 

definition,  history,  etiology..     ..  264 

.symptoms 265 

diagDOsis 268 

morbid  anatomy     269 

morbid  physiology  . .    • 271 

prognosis,  treatment      272 

Acute  bulbar  myelitis        285 

morbid  anatomy      286 

.\cute  central  myelitis       285 

morbid  anatomy      285 

.\cute  cervical  transverse  myelitis  . .     . .  287 

Acute  diifused  myelitis 272 

definition,  etiology        272 

symptoms 273 

course         278 

morbid  anatomy      279 

microscopical  examination  . .     . .  281 

morbid  physiology 283 

varieties 28 1 

diagnosis 288 

prognosis 290 

treatment 291 

Acute  disseminated  myelitis 288 

morbid  anatomy      288 


PAGE. 

Acute  dorsal  transverse  myelitis     . .     . .     287 
Acute  dorso-lumbar  transverse  myelitis    287 

Acute  encephalitis      727 

Acute  hemilateral  myelitis      287 

Acute  inflammation  of  the  grey  anterior 

horns 105 

Acute  myelo-meningitis 288 

morbid  anatomy      288 

Acute  neuritis      i.  293 

Acute  pysemic  encephalitis      728 

Acute  spinal  leptomeningitis 391 

Acute  transverse  myelitis 286 

Acute  universal  cerebral  anasmia  . .     . .     686 
Acuteness  of  vision,  diminution  of       .  .i.  315 

tests  of        i.  315 

Addison's  disease         i.  591 

Adductorsof  both  thighs,  contracture  of  i.  505 

Jisthesioneuroses i.  80,  i.  81,  i.   90 

articular i.  Ill 

osseous        i.  Ill 

visceral       1.113 

Afferent  fibres,  trophic  centre  of     . .      .  .i.  281 

After-sensations,  persistent      i.  101 

Agraphia        616 

Age  as  px'edisposing  to  disease i.    74 

Akinesis i.    86 

reflex        1.137 

of  the  voluntary  muscles     i.  121 

associated  symptoms      1.122 

Alcoholic  paraplegia 955 

Alcoholic  nervous  diseases        953 

Alternate  hemiplegia 669 

Amaurosis  i.  813 

symptoms 1.315 

tabetica       i.  329 

Amblyopia i.  313 

symptoms i.  315 

Amimia 616 

Amoeboid  movements        i.      7 

Amyotrophic  lateral  sclerosis 256 

symptoms 256 

Amygdaloid  nucleus 450 

Amyloid  corpuscles 86 

Anaemia i.  234 

Anaemia  of  the  brain 685 

history,    experimental    investiga- 
tion   685 

etiology       686 

acute  universal 686 

clironic  universal     687 

symptoms 688 

infantile      689 

morbid  anatomy      689 

morbid  physiology 690 

cause,  diagnosis,  prognosis    . .      . .     691 

treatment 692 

Anaemia  of  the  medulla  oblongata  . .     . .     313 

Anaemia,  local,  of  the  skin       i.  188 

Anaemia  of  the  spinal  cord       310 

Anaesthesia i.    83 


982 


INDEX. 


PAGE. 

Anaesthesia  : 

acoustic      i.  355 

auditory     i.355 

ciroumsoribed i.    99 

cutaneous i.    97 

in  the  form  of  a  girdle i.    99 

of  the  larynx  i.  418 

muscular    .. i.  110 

olfactory i.  308 

optic i.  313 

partial         i.  317 

of  sexual  feelings i.  117 

tactile i.  100 

thermo        i.  100 

in  the  territory  of  the  vagus        .  .i.  117 

Anesthesia  dolorosa i.  304 

Analgesia       i.  84,  i.  97,  i.  100 

■visceral       i.  116 

Aneurisms,  intracranial 557 

Angina  pectoris i.  577 

etiology      i.  577 

symptoms i.  578 

morbid  anatomy      i.  579 

morbid  physiology  ..  ■ i.  580 

varieties i.  581 

diagnosis,  prognosis        i  582 

treatment i.  583 

Angioma        557 

Angioneuroses      i.  182 

cerebral      i.  186 

cutaneous i.  187 

peripheral i.  185 

spinal i.  185 

visceral       i.  189 

Angioparalysis      i.  185 

Angioparesis i.  185 

Angiospasm i.  185 

Anidrosis        i.  219 

Ankle  clonus i.  150 

Ankle  reilex i.  150 

Anosmia i.  808 

traumatic L309 

prognosis,  treatment      i.  310 

Ankle  clonus         i.  150 

Ankle  reflex  1150 

Anosmia        i.  308 

traumatic ..     ..i.  309 

prognosis,  treatment       i.  310 

Antagonism  between  size  of  unit  and 

absorption  i.    13 

Anterior  fossae  of  the  skull,  lesions  in   . .     651 

Anterior  grey  horns 8,  33,  37 

dcTelopment  of        28 

Anterior  muscles  of  the  leg,  spasm  of  .  .i.  522 
Anterior  pyramids  . .  . .  i.  52,  83,  65,  69 
Anterior  root.zones     . .     33,  85,  51,  57,  64,  69 

Aphasia,  ataxic 616 

amnesic       618 

morbid  anatomy      ....     . .     621 

morbid  physiology 628 

mechanism  of 629 

Aphonia  paralytica     i.  4i3 

spastica       i.  419 

Apoplexy,  meningeal 881 

Apoplexy,  spinal 321 

Apselapbesia         i.    97 

Arachnitis      390 

Arachnoid,  cranial  part  of        3 

spinal  part  of 410 

Aa-cuate  fibres       34,  37,  61,  62,  458 

Area  of  anterior  cerebral  artery.  440,  441,  442 

lesions  in 640 

Area  of  middle  cerebral  artery       . .    442,  443 

lesions  in 594 

Area  of  posterior  cerebral  artery    . .    440,  441 

lesions  in 633 

Areas  of  the  skull,  respective  contents 

of 426 

Argyll-Robertson  symptom      i.  356 


PAGK. 

Arsenic i.  260 

Arteries  of  brain 439 

of  cerebellum 11 

of  medulla  oblongata 15 

of  pons  Varolii         15 

of  spinal  cord 19 

Arthroneuralgia i.  Ill 

general  symptoms i.  112 

Articular  sesthesioueuroses       i.  Ill 

Arythmia  cordis i.  181 

Ascending  degeneration     95 

Aspermatism i.  118 

Assimilation i.  9,   i.  11 

Associated   movements   of  articulation, 

disorders  of        i.  174 

Associated  movements  of  the  extremities, 

disorders  of        i,  173 

Asthma  bronchiale     i  429 

symptoms  i.  430 

prognosis,  pathology,  treatment,  .i.  431 

Asthma  nervosum       i.  429 

Atavism i.    74 

Ataxia,  locomotor       i.  157 

Ataxic  gait 219 

Ataxy,  locomotor,  progressive 211 

Athetosis        579 

Atony      1.178 

Atrophia  musculorum  lipomatosa  . .     . .     185 

Atrophy  of  the  brain 703 

general        502 

Atrophy  of  the  cerebellum      704 

Atrophy  of  the  corpus  calloaum      . .      . .     708 
Atrophy  of  the  face,  unilateral,   pro- 
gressive        i.  570 

Atrophy  of  the  muscles,  simple      . .     .  .i.  204 
Atrophy  of  the  nerves       . .     . .     i.  S9,  i.  299 

Atrophy  of  the  optic  nerve      i.  828 

Atrophy,  muscular,  progressive      . .      . .     145 

Atropine i.  256 

Attacks,  hysterical      889 

hystero  epileptic       927 

epileptic      922 

Auditory  anesthesia i.  335 

Auditory  hyperesthesia i.  334 

Auditory  hyperalgesia        i.  334 

Auditory  vertigo 830 

Aure  epileptice 916 

motor 916 

sensory       918 

vasa-motor  and  secretory      . .     . .     920 

psychical 921 

Automatic  disturbances : 

encephalic i.  160 

peripheral i.  156 

spinal i.  157 

Automatic  movements       i.    85 

Azygos  uvulse,  paralysis  of       i.  407 

unilateral i.  407 

Back,  muscles  of i.  470 

Barsesthesiometer        i.    94 

Basal  ganglia 434 

functions  of       473 

lesions  of 643 

Basedow's  disease i.  560 

Baths      i.  261 

Bedsores i.  230 

Belladonna i.  256 

Bell's  paralysis     i.  368 

Binocular  diplopia      i.  350 

Bladder,  neuralgia  of i.  594 

Blepharospasm     i.  365 

Blood-letting i.  267 

Bones,  nutritive  aifections  of i.  222 

Brachial  plexus,  injuries  to      i.  543 

nerves  of i.  452 

Brain  of  adult  men  and  higher  mam. 
malia  and  human  infant, 
difference  between 471 


INDEX. 


983 


PAGE. 

Brain,  abscess  of : 

diagnosis 7'-'9 

prognosis 740 

treatment 741 

Brain,  anemia  of       685 

Brain,  arteries  of 439 

Brain,  atrophy  of 703 

Brain,  chronic  abscess  of 731 

Brain,  compression  of 721 

Brain,  concussion  of 716 

etiology,  symptoms 716 

course  . .      . .        718 

morbid  anatomy  and  physiology. .  719 

diagnosis     . .             719 

prognosis,  treatment      720 

Brain,  congenital  malformations  of      . .  507 

Brain,  contusion  of 720 

Brain,  cortical  lesions  of 694 

Brain,  development  of       ....             . .  468 

Brain,  general  atropliy  of 602 

Brain,  hyperjemia  of 693 

etiology       693 

symptoms 695 

morbid  anatomy      . .  698 

morbid  physiology 699 

diagnosis     . . 700 

course,  prognosis,  treatment        . .  701 

Brain,  hypertrophy  of       706 

etiology,  By mjitoms 706 

morbid  anatomy      707 

course 708 

diagnosis,  prognosis,  treatment  . .  709 

Brain,  law  of  dissolution  of      607 

Brain,  parasites  of      558 

Brain,  tumours  of       547 

Brain-substance,  heterotoisia  of      . .      . .  709 

Bromide  of  potassium        i.  259 

Bronchial  branches  of  the  vagus,  anges- 

thesia  of i.  117 

Bronchioles,  spasm  of        i.  429 

Bronzed  skm i.  212,  i.  591 

Brown-Seqnard's  spinal  epilepsy    ..     ..i.  155 

Brown-Sequard's  spinal  paralysis  ..      ..  361 

Bulimia i.  114 

Calabar  bean i.  256 

Capsule,  external 438 

lesions  of 650 

Capsule,  internal 438,  467 

fibres  of      . .      . .      ; 459 

lesions  of 568 

Caput  obstipum  spasticum       i.  433 

Carcinoma      i.  302,  404 

Cardiac  plexus,  neuroses  of      i.  438 

Cardialgia      ..     .• i.  588 

Cardiac  nervous  mechanism     i.  179 

action  of i.  179 

disturbances  of i.  180 

Cataleptic  attacks       890 

Catalepsy       904 

etiology       ' 904 

symptoms 904 

course 906 

diagnosis  and  prognosis 911 

treatment 912 

Caudate  nucleus 434 

lesions  of 645 

Causalgia       i.  lOi 

Cell-contents         ..  i.    10 

Cell-membrane i.    10 

Cells  of  Purkinje 414 

Central  grey  column 8,  45 

development  of        30 

functions  of       79 

Central  grey  tube        8 

development  of 22 

Centrum  ovale      428 

lesions 594 

topography  of 428 


PAGE. 

Cephalalgia i.  543 

Cerebellar  projection-system i.    64 

Cerebellar  rigidity       i.  160 

Cerebellar  tetanic  seizures        i.  160 

Cerebellospinal  conducting  paths. .      ..i.    54 

Cerebello-spinal  system     i.    52 

functions  oif       j.    69 

Cerebellum    ..      ..  i.  52,  412 

Cerebellum,  atrophy  of      70+ 

etiology,  symptoms 704 

morbid  anatomy      705 

coraplicatioiis  and  diagnosis. .      . .     705 

Cerebellum,  crura  of i.  52,  412 

exterior  of 412 

fissures  of 412 

folia  of        412 

functions  of       473 

grey  matter  of  . .      . .  i.  62,  413 

intermediate  ganglia  of i.    54 

int-ernal  structure  of       413 

lobes  of       412 

peduncles  of      412 

white  matter  of        413 

Cerebellum,  lesions  in        671 

Cerebral  ansemia 685 

Cerebral  arteries,  aneurism  of 5'i7 

Cerebral  arteries,  occlusion  of 512 

etiology       512 

symptoms 613 

diagnosis,  morbid  anatomy  ..      ..     515 
experimental  investigatious. .      ..     517 

m  rbid  physiology 517 

prognosis,  treatment       518 

Cerebral  capillaries,  occlusion  of    . .     . .     523 

etiology,  symptoms 523 

morbid  anatomy,  course,  prognosis    524 

treatment 524 

Cerebral  eruptions      i.  210 

Cerebral  facial  paralysis i.  376 

Cerebral  heemorihage 625 

Cerebral  hypersemia 693 

Cerebral  maculae 1.189 

Cerebral  multiple  sclerosis        807 

Cerebral  new  formations 653 

Cerebral  osseous  lesions i.  225 

Cerebral  parasites        558 

Cerebral  projection-system        . .        i.  50,  i.  51 
Cerebral  sinuses,  throm  bosis  of       ..      ..     518 

etiology       518 

symptoms 519 

diagnosis,  course      522 

prognosis,  morbid  anatomy  . .      . .     522 

Cerebral  tumours        547 

varieties      553 

Cerebro-spinal  system        i.    -18 

functions  of       i.    59 

Cerebro-spinal  and  cerebello-spinal  sys- 
tems, co-operation  of      . .     . . i.    59 
Cerebro-spinal  multiple  sclerosis    . .      . .     802 

Cerebrum       415 

basal  ganglia  of        434 

convolutions  of 417 

their  development 469 

their  relations  to  the  skull    . .     424 
their  relations  to  the  areas  of 
skull        ..     ...     ..     ..     ..     426 

cortex  of 450 

crura  of      415 

exterior  of 415 

fissures  of 417 

their  relations  to  the  areas  of 

skull        426 

grey  matter  of 448 

internal  parts  of      428 

internal  structure  of      448 

lobes  of       417 

peduncles  of      415 

ventricles  of      432,  433 

white  matter  of        453 


984 


INDEX. 


PAGE. 

Cervical  part  of  the  spinal   cord,   dis- 
eases of      .'     ..1.543 

injury  to i.  543 

Cervical  plexus,  nerves  of i.  444 

Cervical  sympathetic,  compression  of  by 

tumours      i.  541 

Cervical  sympathetic,  injuries  to    ..      ..1.542 
Cervical  sympathetic,   functional  affec- 
tions of       i.  513 

Cervioo-brachial  neuralgia       i  455 

general  characters,  etiology  . .      .  .1.  455 

symptoms i.  456 

concomitant  symptoms 1.457 

diagnosis,  treatment       i.  458 

Cervico-occipital,  neuralgia      i.  443 

Channels  of  conduction,  pathic      . .     . .  i.    92 
tactile      ..     ..i.    92 

Chiasma i.  450 

Chloral  hydrate i.  258 

Chemical  poisons i.    77 

Chorda  tympaui,  lesions  of      i.  340 

nerve  fibres  of    ..     ..i.  372 

Chorea 841 

etiology       814 

symptoms 815 

course,  duration,  and  terminations    820 

morbid  anatomy       821 

morbid  physiology 825 

diagnosis 828 

prognosis 829 

treatment 829 

Chorea,  post-hemiplegic,  of  adults  . .     . .     574 

Chorea,  pre-hemiplegic      573 

Choreiform  movements      573 

Chromatopsia       1.313 

Chromidrosis        1.219 

Chronic  atrophic  spinal  paralysis   . .     . .     136 
definition,  history,  etiology,  symp- 
toms            .     136 

morbid  anatomy      141 

diagnostic 144 

prognosis,  treatment      145 

Chronic  bulbar  myelitis 304 

Chronic  central  dorso-lumbar  myelitis  . .     299 

Chronic  central  myelitis 298 

Chronic  cerebral  abscess 731 

Chronic  cervical  transverse  myelitis      . .     303 

morbid  anatomy      30  i 

Chronic  difliised  myelitis 292 

definition,  etiology 292 

symptoms 293 

course 295 

morbid  anatomy      296 

microscopic  examination       . .     . .     297 

morbid  physiology 298 

varieties      298 

diagnosis,  prognosis,  treatment  . .     305 

Chronic  disseminated  myelitis 305 

Chronicdorso-lumbartransverse  myelitis  302 
Chronic  dorsal  transversa  myelitis . .  . .  302 
Chronic  inflammation  of  the  spinal  cord.    292 

Chronic  myelo-meningitis 304 

morbid  anatomy      304 

Chi'onic  neuritis i.  294 

Chronic  progressive  bulbar  paralysis  . .  173 
Chronic  spinal  leptomeningitis       . .     . .     396 

Chronic  transverse  myelitis      302 

Chronic  universal  cerebral  ansemia       . .     688 

Ciliary  muscle,  paralysis  of     i.  355 

spasm  of 1.344 

Circulation,  intracranial,  morbid  altera- 
tions of       501 

Cinhosis 1.206 

Clarke,  vesicular  columns  of     8,  22,  30,  33,  45 

Claustrum     438,  450 

lesions  of 650 

Clavate  nucleus 50,  61 

Claw-hand     1.486 

Climate  cures        i.  267 


PAGE. 

Clonic  spasms       . .     i.  130,  569 

Coccygeal  nerve 1.510 

neuralgia  of      i.  519 

treatment 1.519 

Cocoygodynia        i.  519 

Coeliac  plexus,  neuroses  of        1.585 

paralysis  in  the  region  of      . .     .  .1.  588 

spasm  in  the  region  of i.  588 

Cognitions     480 

Cold,  as  a  remedy        i.  261,  i.  277 

Cold,  exposure  to i.    76 

Cold  waterpack i.  265 

Colic        1.585 

Colica  saturnina ..     ..i.  585 

Colloid  bodies       86 

Colour-blindness i.  819 

Colour- vision,  tests  of 1.318 

changes  in i.  317 

Columns,  vesicular,  of  Clarke  8,  22,  30,  33,  45 

functions  of       77 

Columns  of  Goll   ..     ..     i.  55,  52,    58,59,  60 

functions  of       83 

sclerosis  of 249 

Columns  of  TUrck       . .     .  .1.  52,  52,  59,  65,  67 

Common  sensations i.     92 

test  of i.    93 

Commotio  spinalis       368 

Com  pound  lateral  sclerosis       256 

Compression  myelitis 303 

Compulsory  movements i.  160 

Concussion  of  brain 716 

of  the  spinal  cord 368 

Conducting  paths,  i.  50,  i.  52,  i.  54,  i.  56,  64-69, 

457-467 

Conduction i.    30 

Conductivity i.    31 

Congenital  spinal  deformities 97 

Congestion  of  the  brain,  active       . .     . .     693 

passive        695 

Couium  . .  i.  255 

Conjugate  deviation  of  the  eyes  and  rota- 
tion of  the  head  and  neck     .  .i.  168 
Connective  tissue,  morbid  changes  of    . .       86 

hyperplasia  of 87 

hypertrophy  of 87 

retraction  of      87 

sclerosis  of 87 

Consciousness,  anatomical  substratum  of    486 

Continuous  tremor      579 

Contractility i.      7 

mechanical        i.  120 

Contraction,  ideo-muscular      i.  120 

Contraction,  law  of     i.  124 

Contractions,  fibrillary      i.  130 

Contracture i.  132 

myopathic i.  132 

paralytic i.  132 

primary  neurotic i.  182 

Convolutions  of  the  brain,  development 

of i.  469 

Convulsion     ..   * i.  131 

relative  liability  of  some  muscles 

to i.  164 

Convulsions,  internal 1.  419 

Convulsions,  unilateral      594 

varieties      595 

Convulsive  tic      i.  361 

Cordis  arythmia i.  181 

Corona  radiata      459 

Corpora  dentata i.  54,  413 

Corpora  geniculata      50,  438,  449 

Corpora  quadrigemina      . .     . .     50,  439,  449 

lesions  of 649 

view  of       i.  284 

C'  'rpora  striata 434,  449,  465 

Corpus  callosum 428 

atrophy  of 703 

Cortex  of  the  cerebrum,  functions  of    . .     478 
grey  matter  of 450 


INDEX. 


985 


PAGE. 

Cortex  of  the  cerebrum  : 

ideational  area  of 486 

lesioua  of 594 

motor  area 48'i 

motor  centre      483 

motor  outlets 483 

sensory  area       482 

sensory  centre . .      . .     483 

sensory  inlets 482 

Cortex  of  the  cerebrum,  giant  cells  of  . .     452 

Cort  ical  affections  of  speech      612 

Cortical  brachial  monoplegia 606 

Cortical  brachial  monospasms. .  ..  595,  596 
Cortical  brachial  protospasms  . .  . .  595,  596 
Cortical  brachio-crural  monoplegia  . .  605 
Cortical  braohio-facial  mouoplegise  . .  607 
Cortical  centres  of  sensation,  localisa- 
tion of 499 

Cortical  crural  monoplegise      602 

Cortical  crural  monospasms     595 

Cortical  crural  protospasms     595 

Cortical  facial  monospasms      . .     . .    695,  598 
Cortical  facial  protospasms      . .     . .    595,  598 

Cortical  hemiplegia 599 

Cortical  mechanisms  of  actions,  localisa- 
tion of        498 

Cortical  unilateral   oculo-motor   mono- 

plegiae 609 

Cough,  spasmodic        1.  450 

Counter-irritation       i.  267 

Cramp i.  131 

Cramps,  co-ordinate i.  161 

Cranial  nerves,  deep  origin  and  surface 

attachments  of 1.283 

place  of  exit  of i.  555 

Crico-thyroid  muscles,  paralysis  of. .      .  .1.  427 

Crura  cerebri        i.    57 

collar  of     467 

crusta  of     . .     .       457 

Crust  of  the  cerebral  peduncle,  fibres  of     459 

Crying-fits     i.  450 

Cimeate  fasciculus      50,  61 

Cutaneous  aneesthesia        i.    97 

symptoms i.    98 

distribution  of i.    99 

Cutaneous  hypersesthesia i.  102 

Cutaneous  hyperalgesia i.  104 

Cutaneous  nerves  of  the  trunk        ..      ..i.  457 
Cutaneous  nerves  of  the  lower  extremity  i.  515 

Cutaneous  paralgesia i.  105 

Cutaneous  reflexes       1.138 

Cutaneous  secretory  affections i.  217 

Cutaneou.s  sensations,  common       ..     ..i.    92 

special i.    92 

tactile i.    92 

Cutaneoiis  trophic  affections i.  208 

theory  of i.  220 

Cycloplegia i.  355 

Cysticercus  cellulosae 558,  564 

Cysts       373,  557 

Daltonism     i.  319 

Dea&ess         i.  336 

Decubitus  aoutus        i.  213 

chronicus  simplex i.  215 

Degenerations       1.234 

secondary 93,  502 

Deiter's  ceDs 7,87 

Delirium  tremens        953 

Dentate  nuclei     i.  54,  413 

Descending  degenerati.m 95 

Deviation,  secondary,  of  the  sound  eye.  i.  172 

Diabetes  mellitus i.  591 

Diagnosis,  general,  pathological     ..     ..i.  244 

topographical 1.241 

Diaphragmatic  paralysis i.  451 

Diaphragm,  clonic  spasm  of i.  447 

treatment i.  448 

Diaphragm,  tonic  spasm  of      i.  447 


PAGE. 

Diaphragm,  tonic  spasm  of,  treatment    i.  447 
Diphtheritic  nervous  disorders        . .      . .     977 

Diplegia  facialis i.  374 

Diplopia,  binocular i.  350 

Direct  cerebellar  fibres       ..      ..      i.  56,  51,  64 
Direct  cerebellar  tract,  functions  of       ..       82 

sclerosis  of 250 

Direct  cerebral  paralysis 592 

Disivssimilation i.  9,  i.  11 

Diseases  of   the   encephalon,   classifica- 
tion of 509 

morbid  anatomy  of 501 

Diseases  of  the  medulla  oblongata,  clas- 

sification  of        100 

Diseases  of  the  spinal  cord,   classifica- 
tion of 100 

Diseases  of  the  nervous  system,  causes  of.  i.    73 

extrinsic     i.    76 

intrinsic      i.    73 

Disseminatud  sclerosis,  see  sclerosis,  mul- 
tiple      801 

Dorsal  muscles     i.  470 

paralysis  of       i.  497 

treatment i.  498 

Dorsal  nerves,  diseases  of i.  493 

Dorso-intercostal  neuralgia      i.  493 

etiology      i.  493 

symptoms i.  494 

diagnosis,  treatment       i.  495 

Double  painful  sensations        i.  101 

Dura  mater,  cranial  part 409 

diseases  of 743 

Dura  mater,  spinal  part 3 

Dura  mater,  spinal,  inflammation  of    .  .i.  384 

Dynamometer       i.  120 

Dyssesthesia i.  104 

Dyscrasic  spinal  ansemia 310 

Dysphagia  paralytica i.  411 

symptoms 1.411 

prognosis,  treatment      i.  412 

Dystrophy,  neurotic i.    89 

Early  rigidity       569 

Eohinococcus  hominis        565  568, 

Eclampsia      945 

definition 945 

etiology       945 

symptoms 947 

course  and  duration        949 

diagnosis,  prognosis        950 

treatment 951 

Eclampsia  nutans       i.  437 

Ecstasy 907 

Eczema i.  209 

Eighth  nerve,  origin  and  attachments  of.i.  287 

n  uclei  of 49 

Electrical  examination      i.  124 

results  of i.  124 

Electrical  stimuli        i.  122 

Electricity     i.  268 

chemical i.  272 

induced       i.  269 

static i.  269 

Electricity,  uses  of      i.  275 

Elementary  motor  disturbances,  varieties 

of ..i.    86 

Elementary  symptoms,  general  classifi- 
cation of    i.    92 

Elephantiatis  Grsecorum i.  213 

Eleventh  nerve,  accessory  nuclei  of       .  .i.    48 

diagram  of 1.  405 

origin  and  attachments  of    . .     .  .i.  289 

EmboU 313,  511 

Embolism      i.  235,  313,  511 

of  cerebral  ai-teries 511 

symptoms 512 

of   arteries    of   the    medulla    ob- 
longata     313 

Emotional  sensations i.    81 


986 


INDEX. 


PAGB. 

Encephalic  automatic  disturbances       ..i.  160 

Encephalitis  . .      722 

acute,   complicating    aflFections  of 

the  skull     727 

acute  pysemic 72S 

around  extravasations 728 

symptoms 729 

around  necrotic  softenings    . .     . .     728 

symptoms 730 

around  tumours       729 

symptoms 730 

diffused       722 

symptoms 723 

local     722 

symptoms 723 

Encephalon 409,  411 

congenital  malformations  of . .     . .     507 

diseases  of 509 

genera)  atrophy  of 502 

haemorrhage  into      525 

general  atrophy  of 502 

law  of  dissolution  of       507 

morbid  anatomy  of 501 

secondary  degenerations  of  . .      . .     502 
systemic  degeneratious  of      . .      . .     503 

tumours  of 502,547,553 

Encephalo-spinal  system i.    48 

functions  of      i.  57 

Bncephalo-spinal  system,  diseases  of    . .     791 

Enchondroma       403 

Eadomysium i.  201 

Endoneurium       i.  282 

Energy,  conservation  of i.      4 

Enteralgia     i.  585 

Epilepsy 913 

etiology       913 

symptoms 915 

course,  duration,  and  terminations  933 

morbid  anatomy      934 

morbid  physiology 936 

diagnosis 940 

prognosis 941 

treatment 942 

Epileptiform  neuralgia      i.  394 

seizures       929 

Epineurium i.  282 

Erect  posture        i.    61 

act  of  acquiring       i.    66 

Erethismic  shock 712 

Eruptions,  cerebral     ..       i.  210 

spinal i.  210 

Erythema       i.  208 

Examination,  electrical      i.  124 

Exanthemata,  acute,  nervous  disorders  of    976 

Excitability,  electrical       i.  123 

Extensor    digitorum    pedis    communis, 

paralysis  of i.  528 

Extensor  longus  pollicis i.  528 

External  capsule 438,  467 

lesions  of 650 

External  kinesioneuroses i.  119 

External  rectus  oouli,  paralysis  of  . .      .  .i.  357 
Externa]  rectus  oculi,  tonic  spasm  of    .  .i.  347 

treatment i.  347 

External  remedies       i.  261 

Extremities,  inferior,  diffused  spasm  of.i.  423 

treatment i.  423 

Eye,  healthy  fundus  of      i.  312 

Eye,  secondary  deviation  of  the  sound  .  .i.  172 
Eyes,  conjugate  deviation  of  and  rotation 

of  the  head       i.  168 

Eyeball,  muscles  of i.  345 

Face,  motor  points  of i.  379 

muscles  of i.  363 

nerves  of i.  385 

sensory  nerves  of      ..  ..      ..i.  391 

Face,  universal  progressive  atrophy  of  .  .i.  570 
history i.  570 


PAGE. 

Face,  universal  progressive  atrophy  of: 

etiology,  symptoms i.  571 

pathology i.  574 

diagnosis,  prognosis        i.  575 

treatment i.  576 

Facial  nerve i.  338 

accessory  nuclei  of  . .     -. 47 

diagram  of i.  362 

diseases  of i.  361 

paralysis  of        i.  368 

etiology       i.  368 

symptoms i.  370 

course i.  375 

diagnosis i,  376 

prognosis i.  378 

treatment i.  378 

Facial  nerve,   deep  origin    and  surface 

attachment i.  287 

spasm  in  area  of  distribution  of    i.  361 

symptoms..     ..     i.  364 

course,  prognosis,  diagnosis  ..i.  366 
morbid  anatomy  and  patho- 
logy   i.  366 

treatment i.  S66 

False  neuroma      i.  302 

varieties  of i.  302 

False  projection i.  352 

Faradic  irritability     i.  123 

Faradisation 1.270 

varieties  of i.^  270 

Faradism        i.  269 

methods  of  application  of    ..     ..i.  269 

Fascial  reflexes i.  153 

Fasciculus  ouneatus 61 

Fasciculus  gracilis       61 

Feelings 481 

Febi'ile  and  post-febrile  nervous  disorders 

953,  975 
morbid  anatomy  and  physiology . .     978 

diagnosis,  prognosis        979 

treatment 980 

Febi'ile  diseases,  acute,  paralysis  of       . .     978 

Femoral  neuralgia       i.  501 

diagnosis,  treatment       i.  502 

Femoral  region,  muscles  of       . .     i.  505,  i.  507 

Fibrillary  contractions       i.  ISO 

Fibroma i.  302,  373,  403 

Fibro-sarcoma       403 

Field  of  vision,  alterations  in i.  316 

test  of i.  317 

Fifth  nerve i.  338 

deep  origin  and  attachments  of  . .  i.  285 
diagram  of  1st  division  of     . .      .  .i.  344 

of  2nd  division  of i.  392 

of  3rd  division  of i.  392 

diseases  of i.  384 

functions  of      i.  384 

ganglion  of i.  285 

Fifth  nerve,  anaesthesia  of       i.  386 

symptoms,  diagnosis       i.  386 

treatment 1.387 

Fifth  nerve,  neuralgia  of 1.387 

etiology       i.  387 

symptoms i.  388 

varieties      1.390 

course,  diagnosis      i.  395 

treatment i.  396 

Fifth  nerve,  neiu-algia  of  the  first  branch 

of i.  390 

of  the  2nd  division  of i.  392 

of  the  3rd  division  of      i.  394 

treatment i.  396 

Fifth  nerve,  paralysis  in  the  region  of 

distribution  of i.  402 

etiology       i.  402 

symptoms i.  403 

diagnosis,  prognosis,  treatment    .  .i.  403 
Fifth  nerve,  spasm  in  the  region  of  dis- 
tribution of       i.  400 


INDEX. 


987 


PAGE. 

Fifth  nerve,  spnsm  in  the  region  of  dis- 
tribution of: 

etiology,  diagnosis i.  401 

prognosis,  treatment       i.  402 

Fifth   nerve,   trophic    aflEections   in  the 

territory  of        i.  398 

Flexors  of  the  leg,  spasms  of i.  512 

treatment i.  512 

Flexor  communis  digitorum  pedis,  para- 
lysis of        i.  529 

Plexor  poUiois  longus,  paralysis  of . .     .  .i.  529 

Foot,  sole  of i.  512 

Foi'ced  movements      i.  162 

Forearm,  muscles  of    . .       i.  480,  i.  484,  i.  485 

surface  of i.  490,  i.  491 

Pormatio  reticularis    . .     . .   35,  36,  56,  68,  69 

Formication i.  105 

Fornix 433,  467 

Fourth  nerve,  origin  and  attachment  of.i.  285 

Fractures,  spontaneous      1.224 

Framework  of  spinal  coid,  compositioa 

of 6 

Franklin isation i.  268 

varieties  of        i.  269 

Franklinism 1.269 

Frictions,  external      i.  267 

Functions  of  the  cortex  of  the  cerebrum.i.  478 

experimental  determination  of   ..i.  488 
Functions,  the  cortical  ideational  area  . .     486 

experimental  determination  of    . .     497 
Functions  of  the  cortical  motor  centres 

483,  484 

experimental  determination  of   . .     488 
Functions  of  the  sensory  cortical  centres 

482,  483 

experimental  determination  of    . .     494 
Fundus    of   the    eye,    ophthalmoscopic 

appearance  of i.  312 

Furrowed  band 413 

Gait,  ataxic 211 

hemiplegic 581 

spasmodic 251 

Galvanic  excitability i.  123 

Galvanisation       i.  273 

varieties  of i.  273 

Galvanism     i.  272 

methods  of  application  of     ..     ..i.  273 

Ganglion-cells       i.  19,  8 

apolar i.    19 

Beale's        i.    21 

bipolar        i.    19 

caudate       i.    19 

multipolar         i.    19 

spherical i.    19 

Ganglion -cells,      morbid     changes     of, 

atrophy  of 84,  85 

colloid  degeneration  of 85 

hypertrophy  of 84 

nucleus,  multiplication  of    . .     . .       84 
pigmsntary  degeneration  of  . .     . .       85 

shrinking  of      84 

vacuolation  of 84 

Ganglion-cell   groups,   longitudinal   dis- 
tribution of  in  tile  spinal  cord       31 
Ganglion-cell  processes,  branched  ..i.  19,  i.  20 

twisted        i.    21 

unbranched        i.  19,  i.  20 

Gasserian  ganglion      i.  285,  i.  .S38 

Gastralgia      i.  588 

Gastric    branches   of   the  vagus,   anaes- 
thesia of i.  117 

Gastric  plexus,  neuroses  of       . .     i.  433,  i.  588 

Gastrodyriia  iieuralgica      i.  588 

General  conviilsions,  theory  of i.  294 

General  diagnosis i.  241 

General  etiology i.    73 

General  morbid  anatomy i.  2:i3 

General  morbid  physiology       i.  233 


PAGE. 

General  pathology       i.      3 

General  prognosis        ..i.  246 

General  symptomatology i.    79 

Giant-ceUs      452 

Girdle  sensation i,  103 

Glands,  trophoneuroses  of        i.  227 

of    the    digestive    tract,    tropho- 
neuroses of i.  227 

of  the  genito-urinary  apparatus,  .i.  230 

lachrymal i.  228 

salivary      i.  227 

of  the  skin i.  218 

Glaucoma  simplex       i.  399 

Glioma i.  302,  372,  373,  563 

Glosso-pharyngeal  nerve i.  338 

diagram  of i.  337 

origin  and  attachment  of      . .     . .  i.  288 

Glossoplegia i.  382 

etiology,  symptoms i.  382 

diagnosis,  prognosis,  treatment  ..i.  383 

Glossy  skin i.  212 

Glottis,  spasm  of i.  419 

etiology,  predisposing  causes       ..i.  416 

occasional  causes      .i.  420 

pathology,  symptoms     i.  420 

concomitant  symptoms i.  421 

course,  diagnosis      i.  421 

prognosis,  treatment      i.  422 

Glottis  vocalis       i.  413 

Glottis  respira''.oria      i.  413 

Gluge's  corpuscles        86 

Gluteal  region,  muscles  of . .      . .    i.  506,  i.  507 

Glycosuria i.  191 

Goll,  columns  of i.  55,  33,  60,  61 

functions  of       83 

Graphospasmus i.  464 

paralytic  form,  symptoms     ..      ..i.  466 

spastic  form,  symptoms i.  465 

tremulous  form,  symptoms  . .      .  .i.  465 

varieties      i.  466,  i.  467 

etiology      i.  467 

diagnosis,     prognosis,     treat- 
ment        i.  468 

Gratiolet,  optic  radiations  of    . .     . .  i.  51,  459 

Graves'  disease      i.  560 

etiology,  symptoms i.  561 

morbid  anatomy      i.  565 

morbid  physiology i.  566 

diagnosis,  jDrognosis,  treatment  . .  1.  569 

Grey  degeneration       i.  234 

Grey  matter,  composition  of 8 

of  the  cerebellum 413 

of  the  cerebrum       448-458 

of  medulla  oblongata,  superadded.      50 

Grey  substance     i.    35 

of  the  cerebrum      448-458 

of  the  encephalon i.    48 

of  the  medulla  oblongata      . .     . .  33-50 

of  the  spinal  cord 8,  21-23 

development  of        22-31 

rearrangement  of 33-37 

resistance  to  disease  of 87-92 

Growth i.      9 

reproduction  and  action,  antago- 
nism between    i.    12 

Gumma i.  302,  337,  557 

Gustatory  nerves,  aneesthesia  of     . .     . .  i.  341 

diseases  of i.  336 

distribution  of i.  339 

hyeraBsthesia  of i.  340 

paresthesia  of i.  341 

Gymnastics,  Swedish i.  268 

Hsematomyolia 321 

Hsematomyelitis 285 

symptoms 285 

Hsematorrhachis 381 

etiology       381 

symptoms 382 


988 


INDEX. 


PAGE. 

HsematorrhacMs : 

varieties      382 

course,  diagnosis,  prognosis  . .     . .     383 

treatment 384 

Hsemidrosis i.  220 

Hasmorrhage  into  the  substance  oif  tlie 

cerebellum 671 

Haemorrhage  into  the  substance  of  the 

cerebrum 525 

Hsemorrhage  into  the  medulla  oblongata  327 
Hfemorrhage  into  the  spinal  cord  . .  . .  321 
Hasmorrhage  of  the  intracranial  meninges  343 
Hasmorrhage  of  the  spinal  meninges  . .  881 
Hsemori-hagio  internal  spinal  pachy- 
meningitis   386 

definition,  etiology 386 

symptoms 389 

morbid  anatomy      390 

treatment 390 

Hair,  trophic  disorders  of i.  216 

Hand,  muscles  of        i.  363 

spasm  of  interosseous  muscles  of.  .i.  391 

Head,  muscles  of i.  363 

Head,  sensory  nerves  of i.  391 

Headache       i.  54:i 

varieties  of        i.  544 

Healthy  muscle,  structure  of i.  201 

Heart,  accelerator  nerves  of i.  181 

disorders  of  the  rhythm  of   . .     .  .i.  181 
inhibitory  mechanism  of      ..     ..i.  179 

innervation  of i.  179 

reflex  mechanism  of       i.  179 

Hemeralopia         i.  319 

Hemiansesthesia i.  100 

cerebral       582 

morbid  anatomy 583 

Hemianassthesia,  hysterical      . .      . .     . .     871 

Hemianopsia        1.319 

varieties  of        i.  320 

Hemiataxia 581 

Hemiatrophia  facialis  progressiva  ..     ..i.  570 

Hemicrania i.  547 

etiology       i.  547 

symptoms i.  549 

varieties     i.  551 

courses,  diagnosis i.  552 

morbid  anatomy  and  physiology,  .i.  553 

treatment i.  556 

Hemiopia       i.  319 

Hemi paraplegia  spinalis 361 

Hemiplegia i.  121,  568,  .599 

alternate 669 

facialis        i.  368 

spinalis       361 

Hemiplegia,  spastic,  of  infancy       ..     ..     576 

Hemiplegic  walk 581 

Hemispasm 569 

Hepatalgia i.  590 

Hereditary  predisposition i.    73 

Herpes i.  209 

zoster i.  398 

Heterotopia  of  brain  substance       . .     . .     709 

Hiccough       i.  447 

Hip,  spastic  contracture  of      i.  504 

Hippus i.  348 

Histrionic  facial  spasm      i.  361 

Hydrate  of  chloral      i.  258 

Hydrocephaloid  disease     689 

Hydrocephalus,  acute 754 

etiology       754 

symptoms 754 

course,  duration,  and  terminations   761 

morbid  anatomy       762 

morbid  physiology 767 

diagnosis 768 

prognosis    . .     . .  ■ 769 

treatment 769 

Hydrocephalus,  chronic 770 

definition 770 


PAGE. 

Hydrocephalus,  chronic  : 

etiology       770 

symptoms 771 

course,  duration,  and  terminations    772 

morbid  anatomy      773 

morbid  physiology 773 

diagnosis 773 

prognosis 774 

treatment 774 

Hydrophobia 855 

definition 855 

etiology       855 

symptoms 855 

course,  duration,  and  terminations    855 

morbid  anatomy      858 

morbid  physiology 862 

diagnosis 863 

treatment 864 

Hyperaesthesia      i.    83 

Hypalgesia i.    84 

Hyperacute  central  myelitis 284 

Hyperaemia      .      ..     i.  234 

local,  of  the  skin      i.  188 

Hypersemia  of  the  brain 693 

of  the  medulla  oblongata      . .     . .     327 

of  the  nerves     1.292 

of  the  spinal  cord 317 

of  the  spinal  membranes       . .     . .     317 

Hypersesthesia      i.    83 

auditory     i.  334 

cutaneous i.  102 

cutaneous  thermo i.  103 

muscular i.  110 

olfactory i.  304 

Hypersesthesia,  distribution  of       ..     ..i.  103 

Hypersesthetic  spots 1.104 

Hyperakusia i.  334 

Hyperalgesia i.    83 

auditory     i.  334 

cutaneous i.  104 

muscular i.  110 

olfactory i.  807 

visceral        1.113 

Hyperidrosis 1.218 

unilateral 1.543 

Hyperkineses,  professional       ..•   ..     ..i.  464 

Hyperkinesis i.    86 

reflex i.  137 

theory  of i.  305 

Hyperkinesis  of  voluntary  muscles        .  .i.  130 

varieties      i.  130 

concomitant  symptoms i.  133 

consecutive  symptoms i.  134 

painful  points i.  134 

Hyperosmia 1.307 

Hyperpselaphesia i.  102,  i.  551 

Hypertony i.  178 

Hypertrophic    internal     spinal     pachy- 
meningitis          386 

definition,  etiology 3S6 

symptoms 387 

morbid  anatomy      339 

treatment 390 

Hypertrophy,  neurotic      ,     ..i.    88 

of  the  brain        706 

of  the  nerves 1.301 

Hypnotism 908 

Hypogastric  plexus,  neuroses  of     ..     ..1.591 
Hypoglossal  nerve,  accessory  nuclei  of  . .       48 

diagram  of 1.  381 

origin  and  attachment  of      . .      .  .i.  289 

Hypoglossal  nerve,  diseases  of i.  380 

Hysteria 865 

etiology       865 

symptoms 867 

course,  progress,  and  terminations    891 
morbid  anatomj'  and  physiology. .     892 

diagnosis 894 

prognosis 886 


INDEX. 


989 


PAGE. 

Hysteria  : 

treatment 896 

Hysterical  aphonia      i.  428 

attacks        889 

paralysis 873 

Hysterical  paraplegia ^44 

Hystero-epileptic  attacks 927 

Idio-muscular  contraction        i.  120 

Impotency 1.118 

Individual  motor  mechanisms : 

elementary  affections  of        ..     ..i.  119 
Individual  sensory  mechanisms : 

elementary  affections  of i.    92 

Infancy,  spastic  hemiplegia  of 576 

Infantile  spinal  paralysis 106 

Inferior  extremities,  diffused  spasm  of.  .1.  423 

treatment  . .     . ,     i.  423 

Inferior  maxillary  nerve,  diagram  of  .  .i.  393 
Inferior  obliquus  oculi,  paralysis  of  . .  i.  355 
Inferior  rectus  oculi,  pai'alysis  of   . .      .  .i.  354 

Inflammation       i.  234 

Infra.masillary  neuralgia i.  394 

Infra-orbital  neuralgia      i.  394 

Inhibitory  mechanism  of  the  heart       .  .i.  179 

disturbances  of i.  180 

Insane,  osseous  lesions  in  the i.  227 

Inspiratory  spasm       i.  449 

Insular  sclerosis,  see  sclerosis,  multiple . .     801 

Intellectual  sensations       i.    81 

Intermittent  tremor 579 

Intermittent  spinal  paralysis 343 

morbid  physiology,  diagnosis       . .     344 

Internal  capsule 438,  457 

fibres  of      459 

lesions  of 568 

Internal  convulsions i.  419 

Internal  organs,  sensory  affections  of  .  .1.  113 
Internal  rectus  oculi,  paralysis  of  . .     .  .i.  354 

Internal  remedies       i.  254 

Interosseous  muscle,  attachment  of      . .  i.  462 

Intracranial  aneurisms      557 

Intracranial  cerebral  hsemorrhage  . .     . .     525 
definition,  history,  etiology  . .      . .     525 

symptoms 529 

morbid  anatomy     535 

prognosis 537 

treatment 539 

Intracranial  circulation,  morbid  altera- 
tions of       501 

Intracranial  meningeal  haemorrhage     . .     543 

definition,  etiology 543 

symptoms 544 

morbid  anatomy      545 

prognosis,  treatment      546 

Intracranial  new  formations,  varieties  of    553 

Intracranial  tumours 547 

definition,  etiology ,     ..     547 

symptoms 548 

morbid  anatomy      553 

varieties      653 

morbid  physiology 558 

grouping  of  the  symptoms    . .     . .     559 

diagnosis 562 

diagnosis    of  the    nature    of  the 

tumours      564 

prognosis 566 

treatment 566 

Intracranial  parasites 558,564,565 

Intracranial  vessels,  occlusion  of  . .  . .  511 
Inward  rotators  of  upper  arm,  paralysis 

of i.  471 

Iodide  of  potassium i.  259 

Iridoplegia i.  356 

Irritable  testis      i.  230 

In-itability     ..     ..       i.  80,  i.  30 

faradic i.  123 

Irritation,  local i.    78 

spinal 332 


PAGE. 

Joints,  nutritive  affections  of i.  222 

Kiuesioneuroses i.  85,  i.  91 

external      i.  119 

vascular      i.  182 

visceral       i.  176 

Kcilliker,  central  grey  nucleus  of    . .     . .    7,  8 

Labyrinthine  impressions,  disorders  of.  .L  156 
Lachrymal  glands,  trophoneuroses  of   .  .i.  228 

Lancisi,  nerves  of        428 

Landry's  paralysis       264 

Larynx,  muscles  of ,i.  413 

view  of       . .  i.  414,  i.  415,  i.  424,  i.  425 
Laryngeal  branches  of  the  vagus,  anaes- 
thesia of     i.  117 

paralysis  of        i.  423 

etiology,  symptoms i.  423 

diagnosis i.  428 

prognosis,  treatment       i.  429 

Laryngeal  muscles,  actions  of i.  413 

bilateral  paralysis  of       i.  425 

unilateral  paralysis  of i.  425 

mixed  paralysis        i.  425 

phonetic  paralysis i.  427 

respiratory  paralysis       i.  426 

clonic  spasm  of i.  416 

tonic  spasm  of i.  419 

Laryngeal  nerves,  diseases  of i.  413 

Laryngismus  stridulus       i.  419 

Larynx,  akineses  of i.  418 

anaesthesia  of i.  418 

hypera3sthesia  of      i.  418 

hyperkineses  of        i.  418 

parsesthesise  of i.  418 

parakineses  of i.  418 

paralysis  of        i.  423 

sensory  affections  of        i.  418 

Latent  lesions       634,  640 

Lateral  columns,  crossing  of 33 

Lateral  cutaneous  nerve  of  the  thigh, 

neuralgia  of      i.  501 

Lateral  sclerosis 251 

amyotrophic,  symptoms 256 

combined 258 

primary      251 

definition,  etiology 251 

symptoms 251 

course 256 

secondary 259 

morbid  physiology,  diagnosis       . .     262 

prognosis,  treatment      263 

Lateral  ventricles        432 

hsemorrhage  into     655 

Late  rigidity 570 

Latissimus  dorsi,  paralysis  of i.  471 

Laughing  fits        i.  450 

Law  of  muscular  contraction i.  124 

Left  arm,  surface  of i.  487,  i.  488 

Leg,  muscles  of     . .     . .      i.  527,  i.  528,  i.  529 
Leg,  spasm  of  the  anterior  muscles  of  .  .i.  522 

Leg,  spasm  of  the  flexors  of     i.  522 

Leg,  surface  of     . .  i.  530,  i.  531,  i.  532,  i.  633 

Lenticular  nucleus      436,  450,  466 

lesions  of 643 

Lepra  ansesthetica      i.213 

Lepra  nervorum i.  103 

Leptomeningitis  infantium      751 

symptoms 751 

course  and  duration        753 

morbid  anatomy      753 

prognosis  and  diagnosis 754 

Leptomeningitis  spinalis  acuta        . .      . .     391 

etiology,  symptoms         391 

course,  morbid  anatomy        . .     . .     393 

morbid  pliysiology 394 

diagnosis,  prognosis 395 

treatment 396 

Leptomeningitis  spinalis  chronica  . .     . .     396 


990 


INDEX. 


PAGE. 

Leptomeningitis  spinalis  chronica  : 

etiology      396 

symptoms 397 

course,  morbid  anatomy,  diagnosis    398 

prognosis,  treatment      399 

Lesions  of   the  nervous  system,  classifi- 
cation of  i.  233 

Lesions  according  to  the  alteration  of 

function      i.  237 

237 

destroying 

discharging        

irritative 

Lesions  according  to  their  form 

circumscribed 

focal    

diffased       

liistological        

molar 

molecular 

systematic 

Lesions  according  to  their  nature  . . 

compressive       

degenerative      i.  234, 

inflammatory i.  234, 

neoplastic 

toxic 

traumatic 

vascular      i.  234, 

Lesions  according  to  their  situation 

encephalic 

peripheral 

spinal 

Lesions  of  the  reflex  mechanism    . . 

localisation  of- 

Leucoderma,  partial 

Levator  anguli  scapulse,  paralysis  of     . . 

Levator  palati,  paralysis  of      

Levator  paipebrae  superioiis,  paralysis  of 

spasm  of 

Ligameutum  denticulatum      

Lightning  pains i.  105 

Lipoma 557 

Liver,  neurotic  enlargem.ent  of       . .     .  .i.  192 
Living  matter,  fontamental  properties  of  i.     5 

Local  irritation i.    78 

Locality,  tesc  of  the  sense  of i.    95 

Locomotor  ataxia        i.  157,  i.  223 

symptoms i.  157,  i.  223 

causes i.  158,  i.  224 

Locomotor  ataxy,  progressive 2 LI 

defanitiou,  history 211 

etiology       212 

symptoms 215 

varieties      235 

course 236 

morbid  anatomy      237 

morbid  physiology 242 

diagnosis 244 

prognosis 245 

treatment 246 

Locus  niger 449 

Lordosis 115 

Lower  extremity,  cutaneous  nerves  of  .  .i.  515 

Lumbar  neuralgia       i.  499 

etiology      i.  499 

Lumbar  plexus,  diagram  of     i.  600 

diseases  of i.  493,  i.  499 

Lumbo-abdominal  neuralgia i.  499 

Luys,  superior  olive  of       60 

Lymph-space,  sub-arachnoidal        . .        5,  410 
sub-dural 6,  410 

Maculse  cerebrales       1.189 

Main  en  griffe       i.486 

Malformations  of  spinal  cord 97 

Massage i.  267 

Masticatory  paralysis i.  402 

etiology      1.402 


237 
237 
237 
235 
235 
235 
235 
.  236 
236 
236 
236 
234 
235 
245 
245 
245 
235 
234 
244 
241 
243 
241 
242 
136 
138 
212 
471 
407 
353 
346 
5 


PAGE. 

Masticatory  paralysis,  symptoms  . .     .  .1.  403 

Masticatory  spasm      1.400 

etiology,  diagnosis 1.401 

prognosis,  treatment      1.402 

Mastodyiiia 1495 

treatment 1.496 

Mechanical  contractility 1.120 

Mechanical  excitability     i.  129 

Medulla  oblongata       411 

accessory  imclei  of 47 

functions  of       70 

grey  substance  of 33,  51 

morbid  anatomy  of 84 

special  nuclei  of       49 

structure  of       6 

superadded  grey  matter  of    . .     . .  50 

view  of 1.  286,  1.  288 

white  substance  of 61 — 70 

Medulla  oblongata,  anaemia  of        . .     . .  313 

Medulla  oblongata,  embolism  of     ..     ..  313 

symptoms 314 

varieties     314 

morbid  anatomy      315 

diagnosis 316 

prognosis,  treatment      817 

Medulla  oblongata,  lijemorrhage  of       . .  327 

symptoms 327 

cause 329 

morbid  anatomy,  diagnosis  . .     . .  330 

prognosis,  treatment       381 

Medulla  oblongata,  hypersemia  of  . .     . .  327 

Medulla  oblongata,  necrotic  softening  of.  313 

Medulla  oblongata,  slosv  compression  of.  851 

etiology       362 

symptoms 353 

varieties  of  symptoms 356 

cause 357 

morbid  anatomy      367 

diagnosis 359 

prognosis,  treatment      360 

Medulla  oblongata,  thrombosis  of  . .     . .  313 

symptoms '. .  314 

varieties     314 

diagnosis 316 

prognosis,  treatment      317 

Medulla  oblongata,  tumours  of      . .     . .  372 

varieties      372 

etiology      373 

symptoms 374 

localisation  of  tumour 376 

cavise 379 

diagnosis,  prognosis,  treatment  ..  380 

Medulla  oblongata,  wounds  of 346 

etiology       346 

symptoms 349 

morbid  anatomy      350 

cause 351 

diagnosis,  prognosis,  treatment  . .  351 

Melanoma,  multiple  fibrous      403 

M^nifere's  disease 830 

definition 830 

etiology       830 

symptoms          . .  830 

course,  duration,  and  terminations  832 

morbid  anatomy  and  physiology  . .  832 

diagnosis  and  prognosis 832 

treatment 833 

Meningeal  apoplexy 381 

Meningeal  hssmorrhage 543 

Meningitis,  basilar : 

etiology      774 

symptoms 775 

course,  duration,  and  terminations  776 

morbid  anatomy      777 

diagnosis 777 

prognosis 777 

treatment 777 

Meningitis  of  the  convexity  of  the  brain  778 

etiology       778 


INDEX. 


991 


PAGE. 

Meningitis  of  the  convexity  of  the  brain  : 

symptoms 778 

course,  duration,  and  terminations    782 

morbid  anatomy       782 

diagnosis 783 

prognosis 783 

treatment 784 

Meningitis,  epidemic  cerebro  spinal      . .     83+ 

definition 834 

history        834 

symptoms 835 

course  and  duration         838 

complications  and  sequelae    . .     . .     838 

xnorbid  anatomy      839 

moi'bid  physiology 840 

diagnosis  and  prognosis 840 

treatment 841 

Meningitis,  metastatic       ■  784 

etiology      784 

symptoms 784 

varieties      785 

morbid  anatomy      785 

diagnosis,  prognosis,  and  treatment  785 

Meningitis,  traumatic        786 

etiology       7S(3 

symptoms 780 

course,  duration,  and  terminations    788 
morbid  anatomy  and  physiology. .     788 

diagnosis  and  prognosis 789 

treatment 789 

Meningitis,  tubercular,  see  hydrocephalus, 

acute 754 

Mercurial  preparations      i.  260 

Mercurialism 961 

symptoms 961 

treatment 9  2 

Middle  commissure     449 

Migraine         i.  547 

Mimic  convulsion        i.  361 

Mimic  facial  paralysis        i.  368 

Mixed  cranial  nerves,  diseases  of    . .     . .     384 

Mogigraphia i.  464 

Monospasms 594 

varieties  of 595 

cortical        594,  595 

Mons  Veneris,  neuralgia  of       i.  503 

Morbid  nervous  structures  and  functions, 

relations  between i.  237 

Motor  apparatus,  methods  of  examining    119 

general  examination       119 

special  examination        120 

Motor  arresting  pressure  points      ..      ..i.  134 
Motor  cranial  nerves,  diseases  of    ..      ..i.  344 
Motor  exciting  pressure  points        ..      ..i.  134 
Movement  of  the  heart,   regulating  ner- 
vous centres  of i.  179 

Movements,  automatic       i.  8,  i.  85 

reflex i.    85 

spontaneous       i.      8 

voluntary i.    85 

Multiple  sclerosis,  see  sclerosis,  multiple      801 

Muscle,  healthy,  structure  of i.  201 

Muscles,  atrophy  of i.  204 

with  nuclear  prolifeiatioa     ..      ..j.  205 

Muscles,  cirrhosis  of i.  132,  i.  206 

Muscles,  electrical  examination  of..      ..i.  124 

Muscles  of  the  arm,  spasm  of i.  463 

Muscles  of  the  calf,  spasm  of i.  523 

Muscles  of  the  eyeVjall        i.  345 

attachmerits  and  axis  of  rotation  i.  346 
Muscles  of  femoral  region  ..  . .  i.  505,  i.  507 
Muscles  of  gluteal  region  . .  . .  i.  506,  i.  507 
Muscles  of  inspiration,  paralysis  of        .  .i.  451 

varieties      i.  451 

symptoms i.  454 

diagnosis,  treatment       i.  455 

Muscles  of  larynx        i.  413 

actions  of i.  413 

Muscles  of  leg        ..      ..       i,  .527,  i.  528,  i.  529 


PAGE. 

Muscles  moving  the  soft  palate        ..     ..i.  404 

actions  of i.  406 

Muscles  moving  the  soft  palate,  paralysis 

of i.  407 

diagnosis,  prognosis,  treatment   ..i.  409 
Muscles  of  the  jjliarynx      . .      . .     i.  409,  i.  410 

actions  of i.  410 

Muscles  of  the  thumb,  insertion  of . .      . .  i.  462 

Musclesof  the  trunk i.  470,  i.  472 

Muscles,  paralysed,  histological  changes 

m i.  204 

Muscles,relative  immunityof  to  pai'alysis  i.  165 
relative  liability  to  convulsion     .  .i.  165 
Muscles  supplied  by  the  circumflex  nerve, 

paralysis  of        i.  478 

Muscles  supiilied   by  the  crural  nerve, 

paralysis  of i.  506 

Muscles    supplied     by    the    hypoglossal 

nerve,  paralysis  of i.  382 

spasm  of     i.  382 

Muscles  supplied  by  the  gluteal  nerve, 

paralysis  of i.  507 

Muscles  suppUe  i    by  the  median  nerve, 

paralysis  of        i.  484 

Muscles  supplied  by  the  musculo  cutane- 
ous nerve,  paralysis  of    . .      .  .i.  479 
Muscles  supplied  by  the  musculo-spiral 

nerve,  paralysis  of i.  481 

Muscles  supplied  by  the  obdurator  nerve, 

paralysis  of i.  507 

Muscles  supplied  by  the  sciatic  nerve, 

paralysis  of i.  526 

etiology,  symptoms i.  526 

diagnosis,  prognosis i.  532 

treatment i.  533 

Muscles  supplied  by  the  sciatic   nerve, 

spasm  of      i.  522 

treatment i.  523 

Muscular  anaesthesia i.  110 

Muscular  contraction,  law  of i.  124 

Muscular  fibre,  composition  of i.  201 

development  of i.  203 

Muscular  fibre,  striped      i.  201 

termination  of  nerves  in        ..      ..i.  203 

Muscular  hypersesthesia i.  110 

Muscular  hyperalgesia       i.  110 

Muscular  neuralgia i.  110 

Muscular  sense i.  109 

tests  for      i.  109 

Muscular  sensibility i.  109 

tests  for      i.  109 

Muscular  sensoi-y  disturbances        . .     . .  i.  109 

Muscular  trophoneui'O.ses i.  201 

Muscular  tension i.  132 

Mydriasis  paralytica i.  355 

Myelitis,  diffused,  acute 272 

definition,  etiology 272 

symptoms 273 

course 278 

morbid  anatomy      279 

morbid  physiology 283 

varieties     284 

diagnosis 288 

prognosis 290 

treatment 291 

Myelitis,  diffused,  chronic        292 

definition,  etiology 292 

symptoms 293 

course 295 

morbid  anatomy      296 

morbid  physiology 298 

varieties 298 

diagnosis,  pioguoais,  treatment  . .     305 

Myelomalacia       308 

symjitoms,  morbid  anatomy        . .     308 
morbid  physiology,  diagnosis       . .     308 

treatment 309 

Myoneuralgia        i.  110 

Myopathic  contracture      i.  132 


992 


INDEX. 


PAGE. 

lis i.  122 

paralytica i.  356 

spastica  i.  348 

Myxo-giioma 373 

Myxoma 1.302,554 

Myxo-sarcoma      373 

Naevi  pigmentosi        i.  212 

Nails,  trophic  disorders  of i.  216 

Neck,  muscles  of i.  470 

Nerve-centres,  fusion  of i.    45 

Nerve  degeneration 1.194 

theory  of 1.199 

Nerve-fibres,  axis-cylinder  of 1.    22 

connective  tissue  cells  of       ...  .1.    25 

elementary  fibrils  of       i.    21 

Kanvler's  nodes  of 1.    24 

Nerve-fibres,  afferent 1.  30, 1.  281 

arcif  orm     62 

arcuate       34,  61,  62 

centrifugal i.    41 

centripetal i.    41 

commissural      1.    41 

efferent       i.  40,  i.  281 

of  grey  matter 8 

intercentral       i.    41 

medullated        i.    22 

motor 1.    41 

non-medullated        i.    22 

secretory 1.41,1.87 

trophic 1.  41,  i.  87 

varicose       1.    24 

of  white  matter        9 

Nerve-fibres,  alterations  in       1.196 

Nerve-fibres,  functions  of 1.    29 

structure  of       1.282 

Nerve  functions,  general  theory  of. .     .  .1.    33 

Nerve  regeneration     ..  i.  195 

Nerve  stretching i.  278 

Nerves,  atrophy  of      1.299 

idiopathic 1.299 

secondary 1.  299 

symptoms,  prognosis,  treatment.  .1.  300 

Nerves,  congestion  of 1.  292 

Nerves,  cranial,  origin  and  attachments 

of i.  283-i.  291 

places  of  exit  of       1.555 

Nerves  diseases,  causes  of 1.    73 

predisposition  to      1.    73 

Nerves,  electrical  examination  of   . .     .  .1.  124 

Nerves,  hypersemia  of 1.292 

symptoms i-  292 

Nerves,  hypertrophy  of 1.  301 

Nerves,  inflammation  of 1.292 

etiology       i.  293 

symptoms i  293 

course !•  295 

morbid  anatomy      1.  296 

diagnosis !•  297 

prognosis,  treatment      i.  298 

Nerves,  neoplastic  formations  in  ..  ..1.301 
Nerves  of  special  sense,  diseases  of. .  .  .i.  306 
Nerves  of  the  upper  extremity,  paralysis 

of i.  489 

Nervous  asthma i.  429 

symptoms 1.430 

prognosis,  pathology,  treatment  .  .1.  431 
Nervous  lesions,  classification  of  . .  .  .i.  233 
Nervous  system,  accessory  portion  of    ..1.    68 

construction  of  a     i.    42 

fundamental  portion  of i.    68 

law  of  dissolution  of       i.    71 

law  of  evolution  of i.    70 

Nervous  tissues,  compression  of      . .     .  .1.  235 

construction  of i.    35 

degeneration  of        i.  234 

Neuralgia        1.84,1.106 

general  symptoms     . .     . .      1.  84,  1.  106 
painful  points i.  107 


PAGE. 

Neuralgia  : 

points  apophysaire i.  108 

cojicomitant  sensory  symptoms   ..i.  108 
various  symptoms i.  108 

Neuralgia,  ano-vesicalis 1.504 

cervico-brachialis     1.455 

oervico-oocipitalis 1.443 

Neuralgia,  coeiiaca      1.688 

cruralis       1.502 

Neuralgia,  dorso-intercostalis 1.  493 

etiology       1.493 

symptoms 1.494 

diagnosis 1.495 

treatment i.  496 

Neuralgia,  epileptiform i.  395 

Neuralgia,  fernoralis i.  501 

Neuralgia,  gastrica      i  588 

diagnosis i.  589 

prognosis,  treatment       1.590 

Neuralgia  hepatica      i.  590 

symptoms,  treatment 1.590 

Neiiralgia,  hypogastric     i 1.531 

infra-maxillaris        1.394 

Infra-orbitalis 1.394 

Neuralgia  ischiadica 1.509 

etiology       1.509 

symptoms i.  513 

course,  diagnosis       1.516 

prognosis ,     ..     ..i.  517 

treatment 1.519 

Neuralgia  lumbaris i.  499 

etiology,  symptoms i.  499 

Neuralgia  lumbo-abdominalis 1.499 

Neuralgia  mesenterica       i.  585 

etiology,  symptoms i.  585 

pathology i,  586 

treatment i.  587 

Neuralgia  montis  veneris 1.503 

muscular 1.110 

obturator 1.502 

ophthalmica      i.  390 

penis i.  503 

phrenica     1.445 

plantaris     1.517 

pudendo  hsemorrhoidalis      . .     .1.  503 

scrotalis      1.504 

spermatica 1.504 

supra-m axillaris       i.  392 

supra-orbitalis i.  391 

Neurasthenia  spinalis        335 

Neurectomy i.  277 

Neuritis i.  292 

acute 1.  293 

symptoms i.  293 

chronic       1.293 

symptoms i.  294 

course 1.295 

morbid  anatomy      1.296 

diagnosis 1.297 

prognosis,  treatment      1.298 

Neuritis  nodosa i.  295 

Neuroglia      6,  7,  8,  9 

composition  of 6 

development  of        29 

distribution  of 7 

morbid  alterations  of     86 

Neuromata i.  301 

true     1.301 

myelinicum       1.302 

amyelinicum     i.  302 

false 1.302 

varieties  of 1.302 

etiology      1.  303 

symptoms i.  304 

diagnosis,  prognosis,  treatment    .  .1.  305 

Neuro-paralytic  ophthalmia 1.400 

Neurotic  atrophy 1.    89 

dystrophies        i.    89 

paratrophies      1.    89 


INDEX. 


993 


PAGE. 

Neurotic  hypertrophy        ..     ,, i.    88 

Neurotomy i.  277 

New  formations i.  246 

Ninth  uerve i.  338 

diagram  of 1.337 

origin  and  attachment  of      . .     .  .i.  287 

Nucleus 1.      9 

Nucleus  caudatua        432,  434 

lesions  of 645 

Nucleus  lenticularis 436,  450 

Nyctalopia     i.  319 

Nystagmus 1.347 

etiology,  treatment i.  348 

Obturator  neuralgia i.  502 

OblicLuus  inferior  oculi,  paralysis  of     ..1.  355 

Occipital  lobes,  lesions  of 634 

Ocular  muscles,  paralysis  of i.  349 

general  remarks       1.349 

general  etiology       1.350 

general  symptoms i.  350 

course i.  357 

Ocular  muscles,  progressive  paralysis  of, 

see  Ophthalmoplegia  externa    1.  360 

Ocular  muscles,  spasms  of       i.  345 

Ocular  nerves       1.338 

diseases  of 1.  344 

Oculo-motorius,  origin,  and  attachment 

of i.  285 

paralysis  of       1.352 

incomplete i.  353 

(Esophageal  muscles,  paralysis  of  . .     .  .i.  409 

plexus,  diseases  of i.  404 

QSsophagismus i.  114 

(Esophagus,  paralysis  of 1.412 

Olfactory  anaesthesia 1.308 

hyperaesthesia 1.307 

hyperalgesia      i.  307 

Olfactory  lobe       462 

Olfactory  nerve,  diseases  of 1.306 

origin  and  attachments  of    . .     .  .i.  283 

Olivary  body 50,  62 

superior     . .       50 

Onanism        ..i    75 

Operculum 417 

Ophthalmic  neuralgia       1.390 

Ophthalmoplegia  externa 1.360 

symptoms 1.360 

morbid  anatomy      1.361 

prognosis,  treatment       i.  361 

diagnosia,  prognosis 1.358 

treatment i.  359 

Opium 1.  257 

Oppression,  feeling  of       i.  116 

Optic  anaesthesia i.  313 

symptoms .1.  315 

Optic  anaesthesia,  partial i.  319 

Optic  commissure  and  tracts,  diseases  of.i.  319 

symptoms i.  319 

Optic  hyperaesthesia ..     ..1.313 

Optic  hyijeralgesia       1.313 

Optic  lobes 50,  439 

lesions  of 649 

view  of        1.  284 

Optic  nerve,  atrophy  of     . .     . .    i.  323,  i.  328 

simple i.  329 

secondary i.  329 

by  compression 1.329 

symptoms i.  329 

to  optic  neuritis       i.  330 

to  obliteration  of  vessels  ..i.  331 
to  choroido-retinitis  ..  ..i.  331 
to  retinitis  pigmentosa  ..      ..i.  331 

by  excavation i.  331 

morbid    anatomy,    course,    prog. 

nosis        i.  332 

treatment 1.333 

Optic  nerve,  diseases  of     i.  322 

simple  congestion  of       i.  324 

LLL 


Optic  nerve,  structure  of 1.310 

Optic  neuritis       i.  322 

etiology       i.  322 

varieties      i.  323 

symptoms i.  324 

general  symptoms 1.326 

morbid  anatomy       i.  326 

treatment i.  328 

Optic  radiations  of  Gratiolet    . .     . .  i.  51,  459 

lesions  of 582 

Optic  thalami       437,  449,  466 

Optic  tract 415,  461 

chiasma  of i.  284 

origin  and  attachment  of      ..     ..1.283 

vessels  of i.  284 

Oscedo i.  450 

Osmidrosis 1.219 

Osseous  lesions  in  the  insane 1.227 

Osseous  trophoneuroses      i.  222 

of  central  origin       i.  225 

of  peripheral  origin        i.  222 

of  spinal  origin        i  223 

Osteoma 403,  557 

Osteoneuralgia      i.  112 

Outward   rotators    of   the    upper   arm, 

paralysis  of        i.  471 

Ovarialgia      1.592 

Ovarian  hyperaesthesia      i.  592 


Pacchionian  bodies      

Pachymeningitis  cerebralis  externa 

etiology       

symptoms 

morbid  anatomy      

prognosis,  treatment       

Pachymeningitis  cerebralis  interna  hse- 
morrhagica         

etiology       

symptoms 

varieties      

course  and  duration 

morbid  anatomy      

prognosis 

treatment 

Pachymeningitis  spinalis  externa  . . 

etiology,  symptoms 

course,  morbid  anatomy 

diagnosis,  prognosis,  treatment   . . 

Pachymeningitis,    spinalis    interna  hae- 

morrhagica 

symptoms 

morbid  anatomy,  treatment . . 
Pachymeningitis  spinalis  interna  hyper- 
trophica      

definition,  etiology 

symptoms   . .  

morbid  anatomy      

treatment 

Painful  points       i. 

Pains        i. 

Palate,  muscles  of       i.  404,  i. 

Palato-pharyngeus,  paralysis  of      . .     .  .1. 

Papilloma       

Para-anaesthesia,  cutaneous      i. 

Paradoxical  contraction 

Parsesthesia i. 

Paralgesia      i. 

cutaneous i. 

visceral       i. 

Paralysed  muscles,  morbid  changes  in  . .  1. 
Paralysed  parts,  associated  movements  of.i. 

Paralysis  ascendens  acuta 

Paralysis  agitans 

etiology       

symptoms 

morbid  atjatomy       

morbid  physiology 

diagnosis 

prognosis 


410 

743 
743 

744 
744 
745 

745 
745 
745 
747 
748 
748 
750 
750 
384 
384 
385 


386 
389 


886 
386 
387 
389 
390 
107 

81 
406 
480 
556 

99 
225 

84 

84 
105 
113 
178 
163 
2G4 
791 
791 
791 
797 
798 
800 
800 


994 


INDEX. 


PAGE. 

Paralysis  agitans,  treatment 800 

Paralysis,    relative    immunity  of   some 

muscles  to i  164 

Paralytic  contracture i.l32 

Paraplegia     i.  121 

Parapl^gies  dyscrasiques 311 

Parasites,  intracranial       i  557 

Paratrophy,  neurotic i.    89 

Parolivary  body 50 

Partial  optic  aneesthesia i.  319 

Partial  sensory  paralysis i.    97 

varieties  of i.  100 

Partial  sensory  paralysis i.    97 

varieties  of i.  100 

Passive  cerebral  congestion       695 

Patellar-tendon  reflex i.  141 

abolished i.  144 

diminished i.  144 

exaggerated        i.  146 

Pathic  channels i.    92 

Peotoralis  major,  paralysis  of i.  470 

minor,  paralysis  of i.  470 

Peduncles  of  the  cerebellum,  connections 

of 61 

lesions  of 670 

Peduncles  of  the  cerebrum,  lesions  in  . .     669 

Peduncular  fibres,  lesions  of 561 

Pemphigus i.  211 

Penis,  neuralgia  of      i.  503 

Peri-ependymal  myelitis i.  302 

Peri-meningitis i.  384 

Peri-myelitis 391 

Perimysium i.  201 

Peri-neuritis i.  296 

Peri-osteal  reflexes      i.  153 

Peri-pachymeningitis 384 

Peripheral  facial  paralysis        i.  376 

Peripheral   nerves,    automatic    disturb- 
ances of       i.  156 

diseases  of i.  281 

hypertrophy  of i.  301 

trophic  affections  of i.  193 

Peripheral  urinary  paralysis 341 

Peroueus  brevis,  paralysis  of i.  528 

longus,  paralysis  of i.  528 

Pharyngeal  muscles,  actions  of       .,     ..i.  410 

paralysis  of       i.  409 

Pharyngeal  plexus,  diseases  of        . .     .1.  404 

Pharynx,  muscles  of i  409,1.410 

Phonetic  laiyngeal  paralysis,  i.  423,  i.424,  i.  427 

Phosphorus i.  260 

Photopsia       i.  313 

Phrenic  neuralgia       i.  445 

Pia  mater,  diseases  of 751 

Pia  mater,  cranial       410 

spinal 

"  "  ■  406 

212 
438 


Pianoforte  players' spasm 

Pigmentation  of  the  skin,  alterations  in. 
Pineal  body 


Plantar  Neuralgia       i.  517 

81 
405 
404 


Pleasures 

Pneumogastric  nerve,  diagram  of  . . 

diseases  of  

origin  and  attachment  of 

Points  apophysaire     i.  108 

douloureux       i.  107 

painful       i.  107 

pressure      i.  134 

Poliomyelitis  anterior  acuta 105 

definition,  history,  etiology  ..     ..     105 

infantium 106 

symptoms 106 

adultorum 116 

symptoms 116 

course 117 

morbid  anatomy      118 

changes  in  the  paralysed  muscles  118 
localisation  in  the  anterior  horns  127 
morbid  physiology 129 


PAGE. 

Poliomyelitis  anterior  acuta : 

diagnosis 131 

prognosis 132 

treatment  133 

Poliomyelitis  anterior  chronica       . .     . .     136 
definitioQ,  history,  etiology,  symp. 

toms 136 

diagnosis 144 

prognosis,  treatment      145 

Poliomyelopathies       105 

Polysesthesia i.  102 

Polydipsia i.  415 

Polyphagia i.  117 

Pons  Varolii 411 

arteries  of 11 

grey  matter  of 411 

lesions  of 661 

special  nuclei  of       49 

structure  of      411 

white  matter  of       411 

Posterior  and  lateral  combined  sclerosis    258 

symptoms 258 

Posterior  columns,  grey  degeneration  of    211 

sclerosis  of 211 

Posterior  grey  horns 8,  33,  44 

development  of 30 

functions  of       77 

Posterior  roots,  functions  of 77 

Posterior  root-zones    . .     . .       i.  55,  51,  57,  60 

Post-hemiplegic  chorea     574 

Potassium  bromide     i.  259 

iodide i.  259 

Prsefrontal  cortical  lesions       640 

Pi'aehemiplegic  chorea       573 

Pressure,  continuous i.  277 

tests  of  sense  of       i.    94 

Pressure  points i.  134 

Primary  labio-glosso-pharyngeal  paralysis.  173 

definition,  history 173 

etiology,  symptoms 174 

course,      complications,      morbid 

anatomy 181 

diagnosis 184 

treatment 185 

Primary  lateral  sclerosis 251 

definition,  etiology,  symptoms    . .     251 

spasmodic  gait 252 

course         256 

morbid  anatomy      259 

morbid  physiology,  diagnosis      . .     262 

prognosis,  treatment      263 

Primary  neurotic  contracture  . .      .  .i.  133 

Primary  sclerosis  of  the  colum.ns  of  GolL.  249 

Primordial  organisms        i.      6 

Professional  hyperkineses i.  543 

Progressive  locomotor  ataxy 211 

definition,  history 211 

etiology      212 

symptoms 215 

ataxic  gait 219 

reflex  action      224 

occasional  symptoms      .' 225 

paradoxical  contraction . .     . .     225 

varieties     235 

course . .     236 

morbid  anatomy      237 

morbid  physiology 242 

diagnosis 244 

prognosis 245 

treatment 246 

Progressive  muscular  atrophy 145 

definition,  history,  etiology  . .     . .     145 

symptoms 148 

course 159 

morbid  anatomy      160 

morbid  physiology 168 

diagnosis 171 

prognosis,  treatment       172 

Prophylaxis..     i.  250 


INDEX. 


995 


PAOE. 

Prosopalgia i.  368 

Protoplasm i.      7 

Protoapasms 595 

Paammomuui       557 

Pseudo-hypertrophic  paralysis        . .     . .     185 

detinition,  history 185 

etiology      186 

symptoms 187 

course         198 

diagnosis 199 

morbid  anatomy     200 

pathology 208 

prognosis,  ti'eatment      210 

Psychical  actions,  nature  of 479 

disturbances i.    78 

states,  classification  of 480 

Ptosis      i.  353 

Pulmonary  plexus,  neuroses  of       . .     .  .i.  429 

Pyramid,  nucleus  of 50 

Pyramidal  column      61 

Pyramidal  tract   . .      i,  51,  58,  65-67,  462,  484 

accessory  portion  of        68 

functions  of       83 

lesions  of 568 

Pyrosis i.  113 

Quadriceps  extensor  femoris,  spasm  of  . .  i.  505 

Eace,  as  predisposing  to  nervous  diseases  i.    75 

Ran vier's  nodes i.    24 

Rectum,  neuralgia  of i.  592 

Rectus  externus  oculi,  paralysis  of        .  .1.  357 

spasm  of i.  347 

Rectus  interuus  oculi,  paralysis  of. .     .  .1.  354 

spasm  of i.  347 

Rectus  superior  oculi,  paralysis  of. .     .  .1.  353 

Recurrent  sensibility i.  281 

Reeling ,     i.  160 

Reflex  actions,  time  required  for    . .     .  .i.  136 

varieties  of        i.  138 

Reflex  akinesis 1.137 

hyperkinesis      1.137 

Reflex  mechanism  of  voluntary  muscles, 

disturbances  of i.  136 

Reflex  mechanisms  of  the  heart,  disturb- 
ances of      i.  179,  i.  180 

Reflex  movements       i.    85 

Reflex  paraplegia 389-341 

Reflexes,  cutaneous,  stimuli  of       ..      ..i.  120 

deep. i.  140 

fascial i.  153 

periosteal i.  153 

superficial i.  130 

tendinous,  stimuli  of      i.  120 

ReU,  island  of      420 

Remak,  fibres  of i.    22 

Remedies        i.  254 

external      i.  261 

internal         i.  254 

Resxriratory  laryngeal  paralysis. .  i.  424,  i.  427 

Restiform  body 62 

Retro-bulbar  neuritis i.  326 

perineuritis        i.  326 

Rhomboidei,  paralysis  of i.  470 

Rheumatic  lai-yngeal  paralysis        ..     ..i.  428 

Rigidity,  cerebellar i.  160 

early 569 

late       570 

Rolando,  fissure  of      417,  426 

grey  tubercle  of        61 

substantia  gelatinosa  of 7 

Rotation  of  head  and  neck       i.  169 

Sacral  nerves,  diagram  of i.  510 

Sacral  plexus,  neuralgia  in  the  region  of  i.  509 

Salaam  convulsion       i.  437 

Salivary  glands,  trophoneuroses  of. .     .  .i.  227 
Saltatory  spasm 341 


PAGE. 

Saltatory  spasm,  treatment     342 

Sarcolemma i.  203 

Sarcoma 302,373,557 

Saturnine  nervous  diseases       955 

symptoms 956 

morbid  anatomy       959 

morbid  physiology 960 

diagnosis,  prognosis 960 

treatment 960 

Scalp,  nerves  of i.  385 

Schwann,  sheath  of i.    22 

Sciatic  nerve,   paralysis  of  the  muscles 

supplied  by        i.  526 

symptoms i.  526 

diagnosis,  prognosis i.  532 

treatment i.  533 

Sciatic  nerve,  spasm  of  the  muscles  sup- 
plied by       1.522 

treatment i.  523 

Sciatica i.  509 

etiology       i.  509 

anatomical  changes i.  512 

symptoms i.  513 

course,  diagnosis      i.  516 

prognosis i.  517 

treatment i.  519 

Sclerose  lat^rale  amyotrophique  . .  . .  256 
Sclerosis  of  the  columns  of  GoU  . .  . .  249 
Sclerosis  of  the  direct  cerebellar  tract  . .     250 

Sclerosis,  lateral 251 

Sclerosis,  multiple       305,  801 

definition 801 

history        801 

symptoms 802 

course,  duration,  and  terminations    808 

morbid  anatomy      809 

morbid  physiology 810 

diagnosis 812 

prognosis 813 

treatment ' 813 

Scotoma i.  316 

scintillating       i.  316 

Secondary  degenerations 93 

after  amputations 96 

ascending 95 

descending 95 

distribution  of 94 

history  of 94 

Secondary  lateral  sclerosis 259 

symptoms 259 

Secondary  myelitis      340 

Secondary  paraplegia 339 

Secondary  sclerosis  of  the  columns  of  Goll  250 
Secretory  affections,  cutaneous        ..     ..i.  217 

Sensations,  cutaneous i.    92 

common      i.    92 

special         i.    92 

tactile i.    92 

Sensations  of  temperature,  tests  of       .  .1.    96 

Sense  of  locality,  tests  of i.    95 

of  pressure,  tests  of       i.    94 

of  sight,  diseases  of i.  310 

functional  afiections  of  . .     .  .i.  313 

Sense  of  smell,  analgesia  of      i.  308 

hypersesthesia  of      i.  307 

methods  of  testing  ..     i.  306 

Sensibility,  recurrent i.  281 

Sensory  apparatus,  methods  of  examin- 
ing      ....  i.    93 

Sensory  conduction,  test  of  rapidity  of  .  .i.    93 

Sensory  peduncular  tract 459 

lesions  of 582 

Sensory  paralysis,  partial i.    97 

varieties      i.    98 

total i.    97 

Serratus  magnus,  paralysis  of i.  473 

symptoms  . .     . .     i.  473 

treatment i.  478 

Seventh  cranial  nerve i.  338 


996 


INDEX. 


PAGE. 

Seventh  cranial  nerve  : 

accessory  nuclei  of 47 

diagram  of i.  362 

diseases  of  ..     i.  361 

origin  and  attachments  of     . .     . .  i.  287 

paralysis  of i.  368 

spasm  in  the  area  of  distribution  of  .i.  361 

Sex,  as  predisposing  to  disease i.    75 

Sexual  excesses ..     ..i.    75 

Sexual  feelings,  ansesthesia  of        . .     .  i.  117 

Shoemakers'  spasm     /. .     . .  i.  467 

Sick  headache       i.  547 

Silver  salts i.  261 

Singultus       i.  447 

Sixth  cranial  nerve,  origin  and  attach- 
ments of     i.  287 

paralysis  of       i.  357 

Skin,  local  ansemia  of        i.  188 

local  hypersemia  of i.  188 

sensory  disturbances  of i.    92 

sensory  paralyses  of i.    97 

Skin  pigmentation,  alterations  in  . .     .  .i.  212 

Skull,  areas  of       424 

contents  of  the  areas  of  . .     . .     426 

landmarks  on  the  surface  of ..     ..     424 

Slovp  compression i.    76 

Smell,  hallucinations  of j.  307 

illusions  of i.  308 

Sneezing,  attacks  of i.  449 

Soft  palate,  muscles  moving  the     . .     .  .i.  404 

actions  of i.  406 

Soft  palate,  paralysis  of     i.  407 

symptoms i.  407 

diagnosis,  prognosis i.  409 

treatment i.  409 

Soft  palate,  spasm  of i.  407 

Sole  of  foot     i.  512 

Spasmodic  cough i.  450 

Spasmodic  spinal  paralysis        251 

Spasms i.  130 

clonic i.  130 

symptoms i.  130 

tonic i.  131 

symptoms i.  131 

concomitant  symptoms  . .     ..     ..i.  133 

consecutive  symptoms i.  134 

pressure  points i.  134 

Spasmus  inspiratorius        i.  449 

Spastic  hemiplegia  of  infancy 576 

Special  sensations i.    92 

Speech,  disorders  of 612 

emissive  department  of 612 

executive  department  of        ..     ..     615 

mechanism  of 629 

Sphincter  iridis;  paralysis  of i.  355 

spasm  of      i.  348 

Spina  bifida 404 

definition 404 

symptoms 405 

diagnosis 406 

prognosis,  morbid  physiology,  treat- 
ment     407 

Spinal  accessory  nerve,  accessory  nuclei  of    48 

diagram  of i.  405 

diseases  of i.  433 

origin  and  attachments  of    ..     ..i.  289 
Spinal    accessory    nerve,    paralysis    of 

external  branch  of i.  441 

etiology,  symptoms i.  441 

treatment i.  442 

Spinal  accessory  nerve,   spasm    in    the 
region  of  the  external  branch 

of i.  433 

symptoms  ..     i.  434 

diagnosis,  morbid  anatomy  . .     . .  i.  438 

prognosis,  treatment       i.  439 

Spinal  apoplexy 321 

Spinal  arachnitis ,     390 

Spinal  automatic  disturbances        ..     ..i.  157 


PAGE. 

Spinal  cord,  accessory  nerve-nuclei  of   . .       26 

Spinal  cord,  ansemia  of      310 

etiology       310 

symptoms 311 

course,  pathological  anatomy       . .     312 

diagnosis 312 

treatment .      . .     313 

Spinal  cord,  arteries  of      19 

Spinal  cord,  concussion  of 368 

definition,  etiology 368 

symptoms 369 

varieties      . .       369 

morbid  anatomy,  diagnosis  . .     . .     371 

prognosis,  treatment      372 

Spinal  cord,  deformities  of       97 

Spinal  cord,  diseases  of      . .      . .  . .     100 

Spinal  cord,  distribution  of  vessels  of   . .       10 

Spinal  cord,  framework  of       6 

Spinal  cord,  functional  weakness  of      . .     335 

definition 335 

etiology      336 

symptoms 336 

course,  morbid  physiology    . .     . .     337 
diagnosis,  prognosis,  treatment  . .     S'iS 

Spinal  cord,  functions  of 70 

accessory 71 

fundamental     74 

Spinal  cord,  haemorrhage  into  the  sub- 
stance of 321 

definition,  etiology,  symptoms    .       321 
course,  morbid  anatomy        . .     . .     324 

diagnosis     . .     . .  325 

prognosis,  treatment      326 

Spinal  cord,  hypersemia  of       317 

etiology       317 

symptoms 318 

course,  diagnosis      319 

prognosis,  morbid  anatomy,  treat- 
ment     320 

Spinal  cord,  grey  matter  of        .     . .  8,  21 — 37 

Spinal  cord,  malformations  of 97 

Spinal  cord,  membranes  of      3 

Spinal  cord,  morbid  anatomy  of  . .  . .  84 
Spinal  cord,  neuroglia  of  . .  6,  7,  8,  9,  29,  86 
Spinal  cord,  secondary  degenerations  of  93 
Spinal  cord,  simple  softening  of  . .  . .  308 
Spinal  cord,  slow  compression  of    . .     . .     351 

etiology       352 

symptoms 353 

varieties      356 

course,  morbid  anatomy       . .     . .     357 

diagnosis 359 

prognosis,  treatment       360 

Spinal  cord,  structure  of 6 

Spinal  cord,  tumours  of 372 

varieties     872 

etiology,  symptoms 373 

localisation  of  tumours 375 

course 379 

diagnosis,  prognosis,  treatment   . .     380 

Spinal  cord,  unilateral  lesion  of      . .     . .     361 

definition,  etiology,  symptoms    . .     361 

varieties,  morbid  physiology        . .     368 

course 367 

diagnosis,  prognosis,  treatment   . .     368 
Spinal  cord,  white  matter  of     . .      . .   9,  51,  60 

Spinal  cord,  wounds  of      346 

etiology       346 

symptoms 347 

varieties     348 

morbid  anatomy      349 

course 350 

diagnosis,  prognosis,  treatment  . .     351 

Spinal  dura  mater       3 

inflammation  of       384 

Spinal  eruptions i.  210 

Spinal  irritation 332 

definition,  symptoms      332 

varieties      333 


INDEX. 


997 


PAGE. 

Spinal  irritation,  course,  diagnosis        . .     334 

prognosis,  treatment      335 

Spinal  ischsemia 310 

Spinal  leptomeningitis       391 

Spinal  lesions       i.  242 

Spinal  membranes,  deformities  of  . .  . .  405 
Spinal  membranes,  hypersemia  of  . .  317,  381 
Spinal  membranes,  structure  of  . .        3 

Spinal  membranes,  tumours  of       . .     . .     400 

etiology,  symptoms 401 

course,  diagnosis      402 

morbid  anatomy      403 

varieties      404 

prognosis,  treatment       404 

Spinal  meningeal  haemorrhage        . .     . .     381 

Spinal  pachymeningitis     384 

Spinal  paralysis,  atrophic 105 

Brown-Sequard's     361 

intermittent      343 

spasmodic 251 

toxic 344 

Spinal  pia  mater 4 

inflammation  of       390 

Spinalvessels,  morbid  alterations  of  ..  87 
Spleen,  nem-otic  enlargement  of     . .     .  .i.  192 

Splenius  capitis,  spasm  of i.  446 

Spots,  hyperaesthetic i.  104 

Static  ataxia 218 

Sternutatioconvulsiva      i.  449 

StUHng,  nuclei  of i.  54,  50 

Stimulants i.    30 

StimuU i.  7,  i.  27,  i.  30,  i.  32,  i.  120 

electrical i.  122 

Stimulus  and  contraction,  relation  be- 
tween   i.    86 

Stimulus    and    sensation,    relation    be. 

tween i.    82 

Strabismus  convergens      i.  357 

deorsum  vergens      i.  353 

divergens i.  354 

sursum  vergens i.  355 

Striae  medullares 465 

Striped  muscles i.  201 

motor  disturbances  of i.  119 

structure  of       i.  201 

Striped  muscular  fibres,  termination  of 

nerves  in i.  203 

Structure,  differentiation  of i.    14 

integration  of i.    16 

Strychnine i.  255 

Subacute  general  spinal  paralysis  . .  . .  298 
Successive     impressions,     inabUity     to 

count i.  102 

Superficial  reflexes     i.  138 

varieties  of i.  138 

Superior  cervical  ganglion        i.  538 

Superior  olivary  body        50 

Supra-maxillary  neuralgia       i.  392 

Supra-orbital  neuralgia i.  391 

Sweat,  alterations  of i.  217 

Sylvius,  aqueduct  of 439 

fissures  of 417,  426 

Sympathetic  superior  cervical,  ganglion,  i.  538 
Sympathetic  system,  abdominal  part  of.  i.  540 

diseases  of i.  585 

Sympathetic  system,  automatic  actions 

of i.  535 

Sympathetic  system,  cervical  part  of    . .  i.  536 

diseases  of i.  577 

Sympathetic  system,  diseases  of     ..     ..i.  535 

functions  of       i.  535 

reflex  actions  of       i.  535 

Sympathetic  system,  thoracic  part  of   .  .i.  540 

diseases  of i.  577 

Synkinesis     i.  87,  i.  122,  i   162 

Syphilis  of  the  nervous  system        ..     ..     962 

morbid  anatomy      962 

primary  lecions 963 

secondary  lesions      965 


PAGE. 

Syphilis  of  the  nervous  system  : 

967 

lesions  of  the  peripheral  nerves  968 

lesions  of  the  spinal  cord      . .  970 

lesions  of  the  brain 972 

treatment 974 

Tabes  dorsalis,  see  Locomotor  ataxy  . .  211 
Tabes  dorsalis  spasmodica,  see  Primary 

lateral  sclerosis        251 

Tactile  anaesthesia       ..i.  100 

channels i.    92 

TaotUe  and  painful  impressions,  separa- 
tion of i.  101 

Tactile  paralysis,  partial i.    97 

total     ..     i.    97 

Tactile  sensations        i.    92 

Taenia  semioircularis 467 

Tailors'  spasm       i.  467 

Tegmentum,  red  nucleus  of      50 

T«mperatiire,  tests  of  sensation  of  . .  .  .i.  96 
Temporo-spfaenoidal  lobe,  lesions  of  . .  637 
Tendinous  reflexes,  i.  140,  i.  141,  i.  150,  i.  153 

Tensor  palati,  paralysis  of i.  407 

Tenth  cranial  nerve,  diagram  of     . .      . .  i.  405 

diseases  of i.  404 

origin  and  attachment  of      . .     .  .i.  288 

Testis,  irritable i.  230 

neuralgia  of       i.  593 

Tetanic  seizures,  cerebellar       i.  160 

Tetanus $42 

definition,  etiology 842 

symptoms §44 

course,  duration,  terminations     . .     849 

morbid  anatomy      849 

morbid  physiology 851 

diagnosis,  prognosis 852 

treatment 853 

Tetanilla        i.  523 

Tetany '     ..     ..i.  523 

etiology       i,  523 

symptoms i.  524 

Thalami  optici      437,  449,  466 

lesions  of 649 

Thermo-anassthesia     i.  100 

Thigh,  neuralgia    of  lateral    cutaneous 

nerve  of      i.  501 

Third  cranial  nerve,  origin  and  attach- 
ment of       i.  285 

paralysis  of        i.  352 

Thrombosis i.  235,  313,  511 

Tibial  nerve,  paralysis  of i.  528 

Tibialis  anticus,  paralysis  of i.  527 

Tic,  convulsive      i.  361 

douloureux ..     ..i.  394 

Titillation ..     ..j.  114 

Tongue,  muscles  of      1.410 

Tongue,  paralysis  of i,  382 

Tonic  cerebral  spasms        596 

Torpid  shock 711 

Torticollis      i.  433 

Toxic  nervous  diseases       953 

Toxic  spinal  paralysis 344 

Trapezius,  spasm  of i.  434 

Traumatic  anosmia 1.309 

Traumatic  influences i.    76 

Tremor,  a  debilitate i.  130 

coactus        i.  130 

Trepidation  of  extremities        i.  154 

Triangular  nucleus      33,  50 

Trigeminus i.  338 

diagram  of  first  division  of   . .      . .  i.  344 
of  second  division  of       ..      ..i.  392 

of  third  division  of i.  393 

diseases  of i.  344 

functions  of       i.  344 

middle  sensory  nucleus  of     . .     . .       50 

origin  and  attachment  of      ..     ..i.  285 

Trigeminus,  anaesthesia  of        i.  386 


998 


INDEX. 


PAGE. 

Trigeminus,  anaestliesia  of : 

symptoms,  diagnosis       i.  386 

treatment i.  387 

Trigeminus,  neuralgia  of i.  387 

etiology       i.  387 

symptoms i.  388 

varieties      i.  390 

neuralgia  of  the  first  division  of .  .i.  390 
of  the  second  division  of  .  .i.  392 
of  the  third  division  of  . .     .  .i.  394 

course,  diagnosis      i.  395 

treatment i.  390 

Trigeminus,  paralysis  in  the  region  of 

distribution  of i.  402 

etiology       i.  402 

symptoms • i.  403 

diagnosis,  prognosis,  treatment  . .  i.  403 

Trigeminus,  spasm  in  the  region  of  dis. 

tribution  of       i.  400 

etiology,  diagnosis i.  401 

prognosis,  treatment       1.402 

Trigeminus,    trophic    affections   in    the 

territory  of        i.  398 

Trismus i.  400 

Trochlear  nerve,  diagram  of i.  344 

origin  and  attachment  of      ..     ..i.  285 

Trophic    affections    of    the    peripheral 

nerves i.  193 

Trophoneuroses    . .     . .  i.  80,  i.  87,  i  91,  i.  193 

of  the  bones      i.  222 

of  the  cutis        i.  208 

of  the  glands i.  227 

of  the  joints      1.222 

of  the  muscles 1.201 

True  neuroma      ..     ..     ' i.  302 

amyelinicum     i.  302 

myelinicum       1.302 

Trunk,  anterior  surface  of        1.477 

cutaneous  nerves  of        1.457 

muscles  of 1.  470,  1.  472 

Tubercle,  solitary        373,  555 

Tubercula  dolorosa      1.304 

Tumours,  intracranial       547 

spinal 400 

Twelfth  cranial  nerve,  diagram  of. .      .  .1.  381 

accessory  nuclei  of 48 

diseases  of i.  380 

origin  and  attachments 1.  289 

Typhoid  fever,  nervous  diseases  of . .     . .     975 

Unilateral  convulsions       594 

varieties  of        595 

Unilateral  hyperidrosis     1.534 

Unilateral  phonetic  paralysis 

1.  423,  1.  424,  1.  427 
Unilateral  progressive  facial  atrophy     ,  .1.  570 

history        ..1.  570 

etiology,  symptoms 1.571 

pathology 1.  574 

diagnosis,  prognosis        i.  575 

treatment 1.576 

Unilateral  spinal  paralysis       361 

etiology,  symptoms 361 

varieties     363 

morbid  physiology 363 

coui'se 367 

diagnosis,  prognosis 368 

Unstriped  muscles,  structure  of      ..     ..i.  201 

Upper  arm,  muscles  of       1.479 

Upper  extremity,  paralysis  of  the  nerves 

of 1.489 

Urethra,  neuralgia  of 1.  594 

Urinary  paraplegia      339 

Urticaria        i.  208 

Vagus,  anaesthesia  of  bronchial  branches 

of i.  117 

gastric  branches  of i.  117 

laryngeal  branches  of i.  117 

Vagus,  diagram  of       1.405 


PAGE. 

Vagus,  diseases  of        1.  404 

neuroses  of  trunk  of       1.432 

origin  and  attachments  of     ..     ..1.288 

Vagus,  paralysis  of  the  laryngeal  branches 

of 1.  423 

etiology,  symptoms i.  423 

unilateral  and   bUateral  phonetic 

paralyses 1.  424,  i.  427 

respiratory  paralyses.     1.  424,  i.  426 
mixed  paralyses       . .    1.  424,  1.  425 

Vaso-motor  disturbances 1.  182 

varieties     1.184 

Veratrine       1.  277 

Vertigo 1.  160 

auditory     830 

Vesicular  column  of  Clarke       8,  22,  30,  33,  45 
functions  of       77 

Vessels,  intracranial,  occlusion  of  . .     . .     511 

Violin  players'  spasm 1.  466 

Viscera,  diseases  of      i.    78 

innfii-vation  of 1.179 

Visceral  anaesthesia 1.117 

analgesia 1.116 

hyperalgesia      1.113 

paralgesia 1.113 

sensory  disturbances       i.  113 

trophoneuroses  . .     . ;     1.  231 

Vision,  alterations  of 1.315 

alteration  in  the  field  of  . .  . .  1.  316 
changes  in  the  colour  perception  of,  1.  317 
diminution  in  the  acuteness  of    .  .i.  315 

test  of  the  field  of 1.  317 

tests  of  the  acuteness  of 1.  315 

Volitions        480 

Voluntary  movements       1.    85 

Voluntary  muscles,  akinesis  of       ..     ..1.121 

symptoms 1.121 

associated  symptoms      1.122 

electrical  tests 1.122 

Voluntary  muscles,automatlcmechanism, 

affections  of       i.  155 

Voluntary  muscles,  hyperkinesis  of       .  .i.  130 

concomitant  symptoms 1.  133 

consecutive  symptoms 1.134 

Voluntary   muscles,   reflex    mechanism, 

elementary  affections  of. .     .  .1.  136 

Voluntary  muscles,  tonic  spasms  in       . .     343 

Voluptuous  feeling,  excess  of 1.115 

Wallerian  nerve  degeneration 1.194 

Walking 1.    62 

Warmth i.  262 

White  matter  of  the  cerebellum      . .     . .     413 

of  the  cerebrum       453 

of  the  i)ons        411 

of  the  spinal  cord 9 

White  substance 1.    35 

resistance  to  disease  of 92 

White  spinal  substance,  accessory  portion  * 

of 53 

development  of        51 

functions  of       81 

longitudinal  distribution  of  . .     . .       57 

rearrangement  of 33 

Will 480 

Willis,  circle  of 444 

Writers' cramp 1.464 

spastic,  symptoms i.  465 

tremulous,  symptoms     1.465 

paralytic,  symptoms      1.466 

etiology       1.467 

diagnosis,  prognosis,  treatment  .  .1.  468 

Wry-neck       1.433 

symptoms 1.434 

diagnosis,  morbid  anatomy  . .  .  .1.  438 
prognosis,  treatment      1.  439 

Yawning,  attacks  of i.  450 

Zinc 1.260 


E  RE  AT  A. 


Volume  L 

Page  41.  Line  8th  from  the  top,    i 

,,  Line  12th  from  the  top,  [ for  "centre "  read  *'  cortex." 

„  Line  14th  from  the  top,  ) 

,,     48.  Line  16th  from  the  top,  for  "  cenereum  "  read  "  cinereum." 

„    48.  Line  5th  from  the  bottom,  for  "  P  "  read  "  p." 

„     76.  Line  11th  from  the  bottom,  for  "  hoemorrhidal "  read  "  hsemorrhoidal." 

„     77.  Line  2nd  from  the  top,  for  "  adventitse  "  read  "  adventitiffi." 

,,  104.  Line  12th  from  the  top,  for  "  cetkesice  "  read  "  cesthesice." 

„  225.  Line  11th  from  the  bottom,  for  "  cullus  "  read  "  callus." 

,,  258.  Line  11th  from  the  bottom,  for  "  becomes  "  read  "  become." 

,,  449.  Line  5th  from  the  bottom,  for  "  Sternatatio  "  read  "  Siernutatio." 

,,  496.  Line  19th  from  the  bottom,  for  "  injection  "  read  "  injection  of  morphia." 

„  559.  Line  21st  from  the  bottom,  for  "  nitrate  "  read  "  nitrite." 

VoLDfiE  II. 

Page  62.  Line  11th  from  the  bottom,  for  "  ducussating  "  read  "  decussating." 

,,  168.  Line  10th  from  the  top,  for  "  Cruvielhier  "  read  "  Cruveilhier," 

,,  201.  Line  1st  at  the  top,  for  "  Greisinger  "  read  "  Griesenger." 

,,  214.  Line  1st  at  the  top,  for  "  thirty  "  read  "  twenty." 

,,  411.  Line  11th  from  the  top,  for  "  variolli  "  read  "  Varolii." 

,,  411.  Line  16th  from  the  top,  for  "  Variolii "  read  "  Varolii." 

„  427.  Line  19th  from  the  bottom,  for  "  of  the  Skull "  read  "  to  the  Skull." 

„  434.  Line  10th  from  the  bottom,   for    ^'corpora  striatum"  read    "corpus 

striatum." 

,,  558,  Line  19th  from  the  bottom,  for  "  grammes  "  read  "grains." 

,,  641.  Line  15th  from  the  top,  for  "  began  the  "  read  "  began." 


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PALL   MALL. 


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